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EVALUATION OF CLINICAL REASONING OF NURSING STUDENTS IN THE
CLINIC
Introduction
Today’s healthcare environment is dynamic. Nurses must be skilled professionals
capable of providing safe, competent care. High patient acuity, increased patient
demands, and limited staffing all contribute to increased levels of stress amongst nurses
(Berg & Dickow, 2014). Such factors influence the longevity of a nurse’s career, which in
turn perpetuates the nursing shortage.
According to a report from the Carnegie Foundation for the Advancement of
Teaching (2010), there is a need for a radical transformation in the education of nurses.
Nurse educators are challenged to provide appropriate teaching and assessment strategies
that develop students’ critical thinking and clinical reasoning skills (Waters & Rochester,
2012; Yanhua & Watson, 2011). For nursing students, a large amount of education and
learning occurs in the clinical practice setting (Benner 2012; Benner, Sutphen, Leonard,
& Day, 2010) and nursing students must be able to connect theoretical content with
clinical application. There is a need for reliable student assessment strategies to be in
place for faculty and unit staff nurses who serve in the preceptor role. Without reliable
student assessment strategies, student nurses fail to receive an objective evaluation,
which is necessary to develop their ability to think critically and clinically reason (Furze,
Gale, Black, Cochran, & Jensen, 2015).
The educational process of student nurses is a collaborative effort between
schools of nursing and health care facilities (Marchigiano, Eduljee, & Harvey, 2011).
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Nurse educators are responsible for teaching students how to care for patients in the
clinical setting and for assessing students’ understanding of the rationale behind clinical
actions. A primary goal for nurse educators teaching in the clinical setting is to promote
the development of critical thinking and clinical reasoning skills of the students and to
bridge the theory-practice gap (Burrell, 2014; Rencic, 2011). In order to meet the high
standards of national and international organizations calling for new graduates to have
clinical reasoning skills upon entry into professional practice, there must be a reliable and
consistent way for unit staff nurses to assess clinical reasoning (Lasater, 2011).
Faculty and unit staff nurses both serve in nursing students’ development of
critical thinking and clinical reasoning skills; both parties must have consistent and
reliable assessment methods. The purpose of this qualitative case study was to explore the
ability to evaluate students’ critical thinking and clinical reasoning skills in the clinical
setting from the perspective of both the faculty and unit staff nurse. Inconsistencies in
student assessment in the clinical setting can have a negative impact on students’ ability
to develop critical thinking and clinical reasoning skills (Chong, Lim, Liu, Lau, & Wu,
2016).
Definition of the Problem
In the traditional model of clinical nursing education, faculty members
accompany nursing students into the clinical setting and the students’ pair with a unit
staff nurse for the day. Students work under the direction and supervision of a unit staff
nurse while providing primary care for a single patient and assisting in the care for the
remaining patients assigned to the unit staff nurse (Slaughter-Smith, Helms, & Burris,
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2012). The faculty member is present in the hospital and evaluates students’ preparation
for clinical performance, which includes knowledge of medications administered, the
ability to identify critical patient blood tests, and being able to articulate the
pathophysiology of the assigned patients’ diagnoses prior to starting the clinical day
(Ironside, McNelis, & Ebright, 2014).
To perform an evaluation of student nurses, the faculty member uses a variety of
methods throughout the day to assess students’ ability to think critically in regards to
prioritizing patient care and optimizing patient outcomes. In comparison, the unit staff
nurse the student works with is busy taking care of multiple patients and may or may not
have time to assess the student’s knowledge, depending on the patient workload demands
and/or acuity. With heavy patient workloads, the unit staff nurse is less likely to provide
an objective assessment of the nursing student’s ability to critically think and/or clinically
reason (Chuan, & Barnett, 2012; Slaughter-Smith et al., 2012). The unit staff nurse may
not have any training in the assessment process, which further limits the ability to provide
meaningful feedback to the student as pertains to critical thinking and clinical reasoning
(McClure & Black, 2013). Inconsistent assessments of clinical performance by the
faculty and unit staff nurse can lead to confusion and uncertainty, ultimately hindering the
learning process (Benner et al., 2010).
Currently, there are no defining criterion for unit staff nurses to evaluate a
student’s critical thinking and clinical reasoning abilities. This lack of standardization
creates inconsistencies in clinical performance evaluation. Butler et al. (2011) and
LevettJones, Gersbach, Arthur, and Roche (2011) identified the need for a standardized
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assessment tool as well as specific training in the evaluative process of clinical
competency of nursing students. Without a standardized assessment process, students will
continue to experience inconsistent assessments between how faculty and unit staff
nurses perceive their critical thinking ability and clinical reasoning skills. Although
researchers have attempted to create assessment tools, controversy remains on how
critical thinking and clinical reasoning is best evaluated (Butler et al., 2011; Fahy et al.,
2011; Levett-Jones et al., 2011).
The assessment of a complex skill, such as clinical reasoning, can be difficult
even for the seasoned faculty member who has specialized training in nursing education
(Furze, Gale, Black, Cochran, & Jensen, 2015; Nishioka, Coe, Hanita, & Moscato,
2014b). Because nursing students spend the majority of their clinical training time with
the unit staff nurses, the staff nurses’ assessment of students’ performance weighs heavily
in the overall evaluation process (Struksnes et al., 2012). Functioning in the role of
preceptor and clinical educator, the unit staff nurse may have little or no formal education
or experience in the assessment of critical thinking or clinical reasoning skills of nursing
students (Courtney-Pratt, FitzGerald, Ford, Marsden, & Marlow, 2012). Consequently,
students may or may not have an accurate assessment of their critical thinking ability in
the clinical setting, which is not conducive for students’ professional growth (Shipman,
Roa, Hooten, & Wang, 2012).
Rationale
Understanding how unit staff nurses and faculty evaluate and assess critical
thinking and clinical reasoning in the clinical setting will influence how these skills are
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taught to students (Furze et al., 2015). Nursing educational programs strive to develop
nurses who can think critically in the clinical setting in order to achieve positive patient
outcomes. The results from this research study provide critical insight into how faculty
and staff nurses determine the level of competency student nurses possess as related to
their ability to demonstrate effective clinical reasoning and critical thinking skills.
Based on the findings from this research, specific interventions will be
implemented to evaluate the student nurse in a consistent and informed manner by both
faculty and unit staff nurse. This affects a positive social change in nursing education by
decreasing or eliminating conflicting student assessments performed by staff nurses and
nursing faculty. Positive social change will occur because of a triangulated evaluative
process of student performance through two perspectives, one being the educator and the
other being the staff nurse. Consistent evaluations will serve to provide a greater
understanding of students’ strengths and weakness. This will allow further remediation in
areas needing improvement, ultimately producing a safe and competent nurse.
The changes brought about by health-care reform are making significant impacts
on the environment in which nursing students will enter professional practice (Halstead,
2012; Institute of Medicine [IOM], 2010; 2011). Because of these changes, there is an
increased demand for nursing graduates to enter the workforce upon graduation with
developed critical-thinking and clinical reasoning skills. Nurse educators must look for
ways to develop assessment strategies for students in the clinical setting in order to
prepare nursing graduates to work collaboratively and effectively with other health
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professionals in a complex and evolving health care system in a variety of patient care
settings.
Nursing students prepared for practice in this manner will be highly sought after
by employers as possessing competent clinical reasoning skills correlate with the ability
to deliver safe nursing care (Hunter, Pitt, Croce, & Roche, 2014). Clinical reasoning
skills are needed for safe professional practice. Nurse competency is closely tied to
healthcare reform and patient outcomes are increasing being linked to reimbursement
(Dickson & Flynn, 2012).
Evidence of the Problem at the Local Level
The site for this study was a metropolitan area baccalaureate program comprised
of 80 to120 nursing students who participated in medical-surgical clinical placements
each semester (School of Nursing, 2015). The school attracts students from all over the
nation and offers a fast track program that can be completed in sixteen months for
students pursuing a second-degree. The program has no cap on the number of students
entering the program, meaning if the student has met all the prerequisites and qualifies
with the mandatory grade point average (GPA), he or she enters the program. This is
significant to the study as the School of Nursing program graduates a large number of
nursing students entering practice upon graduation twice a year.
According to faculty teaching the Student Leadership course and faculty teaching
the Medical-Surgical courses, in the spring of 2015, the school of nursing identified
trends from the fall of 2014 to the spring of 2015 that revealed inconsistencies between
faculty and unit staff nurses’ assessments of the clinical performance evaluations of
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students. Specifically, the assessment of critical thinking and clinical reasoning skills
(BSN medical-surgical clinical faculty, personal communication, December 5, 2014)
were not demonstrated by students at the competent level. The development and
assessment of clinical performance is essential to developing competencies in nursing
education that ultimately affect patient safety (Stayt & Merriman, 2013). Of particular
importance is the ability to assess a nursing student’s ability to critically think and further
evaluate the student’s ability to clinically reason as it pertains to identifying critical signs
and symptoms, which impact how rapidly interventions are implemented to stabilize
patients (Bucknall et al., 2016).
Faculty members asserted that discrepancies in the assessment of student
performances occur every semester during students’ sophomore and junior years in both
the Adult I and Adult II medical-surgical clinical period, as well as in the medicalsurgical
leadership course (BSN medical-surgical clinical faculty, personal communication,
December 5, 2014). Hart et al. (2015) identified that teaching students how to identify
patient decline begins with early education and assessment of critical thinking and
clinical reasoning skills. Discrepancies in the assessment of critical skills impedes
nursing students’ development of critical thinking and critical reasoning skills, which are
the foundation to identifying patient decline.
This issue was documented in the 2015 February and March baccalaureate, BSN,
faculty-meeting minutes. From these meetings, the faculty from the school of nursing
identified that inconsistency in unit staff evaluations of students’ critical thinking and
clinical reasoning skills occurred in approximately 15-20% of all medical-surgical
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student clinical evaluations. This was an issue needing investigation so that
improvements to the evaluation process could be formulated (BSN medical-surgical
clinical faculty, personal communication, December 5, 2014). Inconsistencies in
performance evaluation negatively affect students’ perception of their ability to clinically
reason and critically think in the clinical setting. According to Bonnel, Gomez,
Lobodzinski, and West (2012), with inconsistency in evaluation of students’ clinical
performance, students’ ability to self-reflect and improve performance is negatively
impacted. Inconsistent evaluation of student performance by clinical staff leads to
discrepancies in student learning outcomes. This has the potential to negatively affect
patient safety outcomes by creating a false perception in how students perceive their
ability to clinically reason and critically think in the patient care setting (Forbes,
Bucknall, & Hutchinson, 2016)
In response to this problem, the faculty pursued reformatting the clinical
evaluation tool and removing staff nurse evaluations. This resulted in a one-sided
assessment of student performance, as students spent the majority of a clinical day with
an assigned unit staff nurse. The staff nurse has a one-on-one relationship with the
nursing student where the faculty member must oversee all students in the clinical setting.
Student nurses spend the majority of their time in the clinical setting learning from a unit
staff nurse (Evans, Costello, Greenberg, & Nicholas, 2013). As a result, the school of
nursing wanted to explore how nursing staff could be included in student evaluations by
identifying why discrepancies occurred between faculty and staff assessments of students.
This fostered the development and implementation of practice improvements to include
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staff nurse evaluations and created consistency and accuracy in how students are
assessed. Mahoney, Hancock, Iorianni-Cimbak, and Curley, (2013) identified practice
improvements are critical to fostering the early development of critical thinking and
clinical reasoning skills of nursing students who are entering the practice.
A staff nurse working with the same student for multiple clinical rotations can
develop a relationship that facilitates learning leading to the identification of how that
student learns best in the clinical setting (Dimitriadou, Papastavrou, Efstathiou, &
Theodorou, 2015). When students have the chance to work consistently with unit staff
nurses, they have the opportunity to identify how the unit staff nurse critically thinks and
makes decisions in regards to patient care (Sharpnack, Koppelman, & Fellows, 2014).
The observations of how the nurse cares for a patient is especially useful to the
student’s learning experience if both faculty and staff appropriately assess the
observation. It is important to know the student’s current skill and knowledge level in
order to set goals that are assessable and obtainable (Rencic, 2011, p. 891). Due to the
complexities in how clinical reasoning and critical thinking of nursing students is
developed, there is an increased need for collaboration between staff nurses and nursing
faculty regarding clinical education and evaluation of student performance in the clinical
setting (Courtney-Pratt et al., 2012; Niederhauser, Schoessler, Gubrud-Howe,
Magnussen, & Codier, 2012). When students have an accurate assessment of their clinical
reasoning and critical thinking skill set and are able to reflect on the information provided
from the assessment, they grow personally and professionally.
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Evidence of the Problem From the Professional Literature
The IOM (2011) reported that competencies in nursing education must move from
lower level thinking skills based assessments to higher order critical thinking and clinical
reasoning assessments. In order to implement this change, there needs to be consistent
evaluation of nursing students from faculty and staff. One of the essential core
competencies that the National League of Nursing (NLN, 2005) identified is the
development of critical thinking skills for nursing students. To meet the NLN’s call for
transformation in nursing education, there needs to be a consistent process to assess
students throughout the learning process (Jensen, 2015; Shipman et al., 2012). Without
consistency in the clinical setting, nursing students lack clarity in learning outcomes and
performance improvement.
Marnocha, Marnocha, and Mason (2014) discussed how better interdisciplinary
communication between staff nurses and clinical instructors provides a more cohesive
academic clinical assessment of student performance. Christie, Hamill, and Power (2012)
reported consistency between unit staff nurses and faculty is a fundamental aspect of
nursing education for nursing students. At the national level, current practices in the
clinical setting revealed faculty and unit staff nurses are inconsistent in evaluating student
critical thinking and clinical reasoning skills (Fahy et al., 2011). Bonnel et al. (2012)
asserted there is a need for identifying the reliability between how faculty and staff
determine student evaluations. Ultimately, clinical evaluation of critical thinking and
clinical reasoning skills helps to develop nurses who can reflect on their performance and
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identify gaps in safe patient practice with the goal of improving their clinical
performance.
Definitions
Clinical Education: Clinical education provides nursing students opportunities for
real-life decision-making and the application of knowledge in a realistic setting
(Gaberson, Oermann, & Shellenbarger, 2014).
Clinical education: Gaberson et al. (2014) described the clinical practice of
nursing education as an environment that is essential for nursing students to experience
real life practice which helps the student apply theory to practice and discover the
purpose of nursing and patient care.
Clinical evaluation/assessment: Bonnel et al. (2012) described formative
assessment in the clinical setting as having a focus on the immediate clinical activity the
student is involved with, and summative assessment assesses assigned outcomes at the
end of the clinical rotation.
Clinical faculty: For the purpose of this study, clinical faculty is expert registered
nurses who supervise nursing students during the semester and perform summative and
formative evaluations of clinical performance (O'Mara, McDonald, Gillespie, Brown, &
Miles, 2014).
Clinical reasoning: Clinical reasoning is the ability of a nurse to assess a large
volume of clinical data and then correctly identify an appropriate nursing action to
address clinical care based problems (Jensen, 2013; Simmons, 2010).
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Clinical rotations: Clinical rotations are healthcare sites where nursing students
have the opportunity to work with unit staff nurses in the clinical setting observing and
performing direct patient care under the supervision of clinical faculty and unit staff
nurses (Andresen, & Levin, 2014).
Critical thinking: Gaba (2015) defined critical thinking as the ability to use
intuition and individual thoughts in a situation that one is accustomed to working in and
come to a conclusion.
Medical-Surgical Clinical: As cited by Marnocha, Marnocha, and Mason (2014),
“Unit-based clinical education takes place in groups of seven to nine nursing students
with one academic clinical instructor in the acute care hospital setting” (p. 45). For the
purpose of this study, this includes the Adult 1 and Adult II clinical rotations for nursing
students.
Novice nurse: The novice nurse is a nursing student in the patient care setting.
The novice-nursing student relies only on what he or she has learned in the academic
setting to make sense of the day-to-day activities in the clinical unit (Jewell, 2013).
Preceptor: Trede, Sutton, and Bernoth (2016) defined a preceptor as unit staff
nurses who work in the healthcare setting and assist in the education of nursing students
by mentoring, teaching as well as providing feedback and assessment of clinical
performance.
Unit staff nurse: Bormann and Abrahamson (2014) identified a unit staff nurse as
a registered nurse who has completed an accredited nursing program (associate or
baccalaureate), and a hospital orientation period and works on an assigned clinical unit
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caring for patients. The unit staff nurse functions as a preceptor for nursing students on
the assigned clinical unit (Slaughter-Smith, Helms, & Burris, 2012).
Significance
Understanding how unit staff nurses and faculty evaluate and assess critical
thinking and clinical reasoning in the clinical practice setting will influence how these
skills develop in students (Furze, Gale, Black, Cochran, & Jensen, 2015). Nursing
educational programs strive to develop nurses who can think critically in the clinical
setting. The results from this research study give critical insight into how the faculty and
the staff nurses determine the level of competency student nurses possess concerning
their ability to demonstrate effective clinical reasoning and critical thinking skills. Based
on the findings from this research, a project was developed (Appendix A) so that student
nurses’ are evaluated in a consistent and informed manner by both faculty and unit staff
nurses.
Nurse educators must ensure that nursing students graduate with a sound
foundation of clinical reasoning skills that can be further developed as the student enters
the workforce as a new graduate (Jensen, 2013). Positive social change in nursing
education has occurred through the development of a 3-day professional development
program for unit staff nurses. After successful completion of the professional
development, unit staff nurses will be better prepared to precept students and assess
critical thinking and clinical reasoning skills in a reliable and consistent manner. This will
further positively affect student nurse clinical practice by developing students who are
safe clinical practitioners.
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The changes brought about by health-care reform are making significant impacts
on the environment where nursing students will enter practice (Halstead, 2012; IOM,
2010; 2011). Because of these changes, there is an increased demand for nursing
graduates to enter the workforce with competent critical-thinking and clinical reasoning
skills. Nurse educators must find ways to develop reliable and consistent assessment
strategies for students in the clinical setting in order to prepare nursing graduates to work
effectively in a variety of patient care settings. Nursing students prepared for professional
practice in this manner developed their self-efficacy, and are highly sought after by
employers (Hunter, Pitt, Croce, & Roche, 2014).
Guiding Research Questions
The following research questions guided this study:
RQ1. What are faculty and staff perceptions concerning the level of preparedness
staff nurses need to assess critical thinking and clinical reasoning ability
of nursing students in the clinical setting?
RQ2. How do the medical-surgical faculty members describe their process of
evaluating the critical thinking and clinical reasoning skills of nursing
students in the clinical setting?
RQ3. How do unit staff nurses describe their process of evaluating the critical
thinking and clinical reasoning skills of nursing students in the
clinical setting?
Review of the Literature
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Organization of the Literature Review
Education and nursing databases were accessed in search of articles related to
assessment of critical thinking and clinical reasoning of nursing students in the clinical
setting. Literature searches were conducted using databases, which included: EBSCO,
CINAHL, MEDLINE, ERIC, ProQuest Central and outside sources which included
Google Scholar. The key concepts and topics which yielded the most results were clinical
education and nurses, critical thinking and nursing, clinical reasoning and nursing,
assessment in the clinical setting, teaching in the clinical setting, and clinical education.
The literature review was organized around the topics, which yielded the most
information relating to assessment of critical thinking and clinical reasoning of students
in the clinical setting.
Conceptual Framework
Benner (1982) introduced the novice to expert theory over 30 years ago; this
theory is still foundational to nursing education and practice. The model describes the
five stages or levels in the development of nurses’ critical thinking and clinical reasoning.
These five phases illustrate the growth in clinical judgment that nurses go through from
the foundations of nursing education into their respective careers. The primary stages of
this theory are the novice, advanced beginner, competent, proficient, and expert. The five
steps form the basis of clinical reasoning in the clinical setting. Assessing nursing
students’ knowledge at each stage of development is essential for establishing growth and
identifying gaps in knowledge. With accurate assessments of student performance,
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teaching strategies can be developed focusing first on critical thinking and then on the
progression of clinical reasoning.
Observing nurses in the clinical setting was foundational in the development of
Benner’s novice to expert theory. This establishes the basis for how nurses make
decisions at different developmental stages. The decisions at each of the five
developmental levels is based on the nurse’s ability to assess changes in the patient’s
condition, recognize the nursing actions required for each scenario, perform
reassessments to evaluate patient outcomes, and develop new nursing actions based on
the patient response (Thompson, Aitken, Doran, & Dowding, 2013). Thompson et al.,
further described a patient’s clinical status can change very quickly due to complex
disease processes, and the nurse is responsible for using the nursing process to identify
and inform decisions about patient care
The first stage in Benner’s (1982) model is the novice nurse and at this stage of
development the nurse or nursing student has no familiarity with the treatment plan in the
context of the clinical setting. There is a focus on task completion and a lack of
knowledge or understanding of the bigger concepts behind decision-making in regards to
patient care (Nummimen et al., 2014). At this stage, successful clinical experiences for
the nursing student rely upon structured learning objectives (Wruble Hakim et al., 2014).
In addition to satisfying the clinical objectives, the student’s learning opportunity is
carefully guided and assessed by faculty who facilitate what the student learn in the
clinical setting (Démeh, & Rosengren, 2015). The nursing students rely only on what
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they have learned in the academic setting to make sense of the day-to-day activities in the
clinical unit (Jewell, 2013).
The next stage is the advanced beginner, which is similar to the novice stage
except that the nurse has now gained minimal experience and begins to see small
connections or patterns on the nursing unit and within patient care (Benner, 1982). The
students’ skills are becoming more developed and more congruent over time. The
advanced beginner relies on knowledge acquired from nursing school, but still struggles
to prioritize patient care and determine overall priorities in the clinical setting (Benner,
2001). Traditionally, this is an accepted stage of development for a new graduate entering
practice. Changes in the healthcare system deem it necessary to make educational
changes in nursing education to begin developing this stage within nursing education
(Benner, 2012).
The third stage is the competent stage and is associated with nurses who have
been in practice for some time and are gaining proficiency in all areas of their respective
fields (Benner, 1982). In this stage, nurses are becoming competent because they are
working in the same clinical area and begin to see and make connections between clinical
patterns, both in the care they deliver to patients and in the prioritization of care in the
clinical setting. Garside and Nhemachena (2013) explained that in Benner's theory, the
competency level nurse provides safe patient care and is more in tune with all aspects of
patient care from providing family support to all aspects of interdisciplinary care. Garside
and Nhemachena identified competence for a nurse entails professional accountability
and recognized development in this area is fundamental for advancing to the next level.
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Although an upper-level skill, the concept of competence needs to be established early in
nursing education and there needs to be a cohesive way for faculty and staff to teach and
assess beginning competencies of nursing students in the clinical setting.
The fourth stage is the proficient stage where the nurse is able to respond quickly
and accurately to changes in patient acuity using intuition that develops over time
(Benner, 1982). The unit staff nurse who is precepting a student nurse in the clinical
setting is aware of this process and begins to develop the student’s awareness to patterns.
Gaba (2015) asserted that clinical reasoning must be developed and fostered by the unit
staff nurse to encompasses all aspects of the disease process from how the disease alters
the body, what nursing care is associated with these signs and symptoms, diagnostics, and
holistically looking at all aspects of patient care.
Gaba (2015) identified that a priority in preparing nursing students to become
better prepared towards proficiency in the clinical setting revolves around linking clinical
reasoning in the classroom to real practice in the clinical setting. This idea goes beyond
the concept of bridging the theory to practice gap and requires faculty and unit staff
nurses to facilitate and continually assess the learning process. Gaba reiterated that the
development of clinical reasoning skills is the foundation for establishing nursing
students who are more readily prepared to enter practice and have a greater ability to
progress from novice to proficient in the clinical setting. Faculty working with unit staff
nurses can develop activities and assessments, which support students developing clinical
reasoning skills to encourage their development towards becoming more proficient in the
clinical setting.
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The last stage is the expert stage. At this point in practice, the nurse can act on
intuition, identify changes in patient acuity that are not textbook clinical changes, and is
proficient in her area of specialization (Benner, 1982). An expert nurse is a skilled
practitioner who has a diverse clinical background and can function as an expert in more
than one location within the hospital or specialty hospital (Camp, 2015). The expert nurse
can interpret the clinical setting and patient responses with intuition and a knowing that
transcends explanation (Master, & Gilmore, 2015). Obtaining the level of expert
registered nurse in the clinical setting takes years and growth in a variety of settings and
is an invaluable resource for teaching clinical reasoning skills to nursing students
(Adelman-Mullally et al., 2013). There is also an expert level of clinical nurse educator
and that person is able to effectively teach clinical reasoning skills and assess students’
responses to learning (Benner, Tanner, & Chesla, 1996). Expert clinicians and clinical
educators respond to a variety of situations in an unconscious approach that is second
nature (Robert, Tilley, & Petersen, 2014).
The language from Benner’s novice to expert theory guides the clinical education
of nursing students by faculty and unit staff nurses. This model establishes a common
language that faculty and unit staff nurses should be using as a guide for consistency in
evaluating the nursing students’ ability to use clinical reasoning skills and critical
thinking in the clinical setting. Benner’s theory sets the stage for teaching clinical
reasoning and assessing it in the clinical setting. Making clinical decisions related to
patient care is the process of using clinical reasoning and critical thinking skills in the
clinical setting (Alfaro-LeFevre, 2015).
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When a nurse begins to recognize untoward signs and symptoms in a patient and
responds by escalating the issue to prevent patient harm, the action demonstrates
experience and intuition (Pearson, 2013). With facilitation and guidance in the clinical
setting, nursing students will become better prepared to enter the practice setting at a
more proficient level. Using Benner’s novice to expert theory facilitates faculty and unit
staff nurses’ ability to assess clinical reasoning abilities of nursing students.
Clinical Education
The clinical environment is essential to meeting the learning outcomes of nursing
education (Löfmark, Thorkildsen, Råholm, & Natvig, 2012). Immersion into the clinical
setting is of utmost importance for nursing students to gain exposure to clinical reasoning
skills and is essential for students entering practice after graduating nursing school
(Burrell. 2014; Chan, 2013; Marchigiano, Eduljee, & Harvey, 2011; Nishioka, Coe,
Hanita, & Moscato 2014a; Rencic, 2011; Slaikeu 2011). Gaberson et al. (2014) described
the clinical practice of nursing education as an environment that is essential for nursing
students to experience real life practice which helps the student apply theory to practice
and discover the purpose of nursing and patient care. Gaberson et al. further identified
that classroom experiences could never adequately prepare a student nurse for practice in
the clinical setting.
Theoretical knowledge gained in the classroom impacts clinical performance but
ultimately, how well the student can put this knowledge into practice is where critical
thinking and clinical reasoning come into play (Hatlevik, 2012). Clinical education
should not be a rigid structure where the faculty member finds and creates the learning
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environment; in contrast, it is best to expose the nursing student to clinical problems that
need multiple solutions (Gaberson et al., 2014). In a meta-analysis done by Shin and Kim
(2013), problem-based learning, such as what occurs in the clinical setting, was identified
as key to the nursing students developing clinical reasoning skills through immersion in a
clinical learning environment.
Clinical education provides nursing students opportunities for real-life
decisionmaking and the application of knowledge in a realistic setting (Gaberson et al.,
2014). Exposure to the clinical environment helps to influence the student’s behavior and
is fundamental in developing the culture of nursing (Henderson, Cooke, Creedy, &
Walker, 2012). Nursing students need exposure and repeated experiences to real life
scenarios in the clinical setting to develop safe nursing judgment (O'Leary, Nash, &
Lewis, 2016). Without the clinical experience, students are unable to connect theory to
practice.
Students do weekly rotations in a diverse clinical environment for the goal of
gaining expertise in the medical-surgical setting (Blomberg et al., 2014). The
medicalsurgical clinical floor routinely has students from a variety of schools, but also is
working with students who possess a variety of skill levels and from “licensed practical
nurse programs to associate degree and Bachelor of Science degree registered nurse
programs” (Slaughter-Smith, Helms, & Burris, 2012, p. 55). This setting creates a
challenging environment for the unit staff nurse to evaluate and assess clinical reasoning
and critical thinking skills as the staff struggles to identify what level of student they are
precepting (Helminen, Coco, Johnson, Turunen, & Tossavainen, 2016). If the staff nurse
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is constantly trying to take care of multiple patients in various degrees of illness, she may
not have time to identify the level of student she is precepting, and this could be
detrimental in the evaluation of the student’s performance (Dolansky, Druschel, Helba, &
Courtney, 2013).
Dolansky et al. (2013) explained busy unit staff nurses might assess student
performance based on how the student did not impose her presence or bother the nurse
during a busy day of patient care. In contrast, Plakht, Shiyovich, Nusbaum, and Raizer
(2013) identified that the faculty member who routinely meets with the student multiple
times, reviews student-preplanning paperwork, and has gone thru and examined the
patient's chart, can readily identify student weaknesses. The unit staff nurse may be a
one-shift preceptor who has not seen the student’s paperwork, is unable to determine the
student’s educational level, and is not familiar with the student’s clinical objectives
(Esmaeili, Cheraghi, Salsali, & Ghiyasvandian, 2014). Each of these issues can affect the
ability to assess the student in a congruent manner with the assigned faculty member.
This setting creates an environment that leads to inconsistencies in the assessment and
evaluation of nursing students’ ability to clinical reasoning and critical thinking.
Evaluation in the Clinical Setting
The clinical setting is an essential part of a nursing student’s educational practice.
As the clinical setting establishes the foundation for students to link theory and practice,
assessment of student clinical reasoning and critical thinking must be part of clinical
education standards (Rubenfeld, Scheffer, & Rich, 2014). Ulfvarson and Oxelmark
(2012) described faculty and unit staff preceptors in the clinical setting lacking
23
knowledge regarding current clinical assessment practices. Assessing nursing student
competence is essential to developing safe practitioners, yet there remains a lack of
consistency and uncertainty in how nursing students are assessed by faculty and staff in
the clinical setting (Zasadny, & Bull, 2015). Henderson et al. (2012) discussed the
clinical setting as a dynamic shifting environment, which needs a thorough evaluation of
student learning and assessment. The evaluation of student performance in the clinical
setting remains challenging because of how fast healthcare is evolving in the 21st
century. Helminen et al. (2016) asserted that there is a prevalence of inconsistencies in
the assessment of student performance in the clinical setting. Helminen et al. further
identified that unit staff nurses may inflate student grades to create a more welcoming
environment.
Kantor (2014) identified the need to reassess how nursing student evaluations are
performed in the clinical setting, as there are variations with little to no consistency from
nursing program to nursing program. Sedgwick, Kellett, and Kalischuck (2014) identified
a discrepancy between clinical partners and nursing program evaluations of student
performance in the clinical setting, and specifically identified the need to engage faculty
and unit staff nurses in discussions to improve assessment processes. Clinical demands on
unit staff nurses influence how student assessment practices are currently done in the
clinical setting affecting assessment consistencies between staff and faculty (Cassidy et
al., 2012). The unit staff nurse who does not have enough time to gauge the student’s
prior experience or learning outcomes can affect and lead to inconsistencies between the
faculty and unit staff nurse’s assessment. Bradshaw et al. (2012) found that there is a lack
24
of consistency in assessing clinical practice due to personal bias revealing a wide
variation in student assessments.
DeBrew and Lewallen (2014) reported one difficulty in assessing students in the
clinical setting relates to clinical evaluation tools lacking a connection with course
learning outcomes. This leads to the assessment tool being too broad and having no valid
link to student clinical performance resulting in a lack of ability to define passing or
failing clinical behaviors. DeBrew and Lewallen asserted that faculty assessment of
students is sometimes difficult to do in the clinical setting as there are many sources to
gather data from in regards to clinical performance and identified that this can lead to
discrepancies in assessment of student performance.
Hegenbarth, Rawe, Murray, Arnaert, and Chambers-Evans (2015) called to
attention inconsistencies occurring among faculty and staff in regards to nursing students’
clinical learning environment. Hegenbarth et al. went on to elaborate that these
inconsistencies should be of concern to both the school of nursing and the hospital and
recommended that future studies examine the perceptions of both faculty and staff in
regards to clinical education of nursing students in the clinical setting. Bengtsson and
Carlson (2015) identified issues unit staff nurses had with assessing student performance
in the clinical setting. Unit staff preceptors in this study reported challenges in evaluating
students that led to inconsistencies with faculty assessment of students. These challenges
relate to students who were not knowledgeable about disease processes and faculty being
unable to recognize deficits in student knowledge. Another issue arose with adult students
dealing with diverse life experiences who posed a challenge for staff nurses to instruct
25
and assess. These situations led to unit staff nurses being uncomfortable with the
assessment of students, which created inconsistencies in assessments.
Formative and Summative Assessment
Two of the primary goals in the evaluation of students in clinical nursing practice
are to evaluate student progress of clinical reasoning and to evaluate the nursing program
as a whole (Kantor, 2014). There is an increased focus on competency-based frameworks,
which outline the core knowledge, skills, and attitudes that nurses need to enter
professional practice. Bonnel et al. (2012) described formative assessment in the clinical
setting as having a focus on the immediate activity the student is involved with, and
summative assessment focusing on assessing assigned outcomes at the end of the clinical
rotation. Nurse educators have an obligation to the profession of nursing to create and
develop environments that foster learning and accurate assessment of nursing students
(Burrell, 2014).
A tremendous amount of education for nursing students, which occurs in the
clinical setting that results from collaborative efforts between schools of nursing and
medical facilities (Marchigiano et al., 2011). Another reason formative assessment is
done is to evaluate the student’s progress and to increase the student’s potential for
success (Kantor, 2014). Formative assessments of nursing students occur daily in the
clinical setting. The practice of evaluation is to assure that students focus on patient
priorities and that they are processing information correctly in the clinical environment in
which they are immersed (Nielsen, Sommer, Larsen, & Bjørk, 2013).
26
The traditional model of clinical education where the student is precepted by the
staff nurse who lacks training in formative assessment contributes to inconsistencies in
student assessments Unit staff nurses must be able to improve their knowledge about
student assessments in the clinical setting and should be versed in formative and
summative assessment standards (Rafiee, Moattari, Nikbakht, Kojuri, & Mousavinasab,
2014). Lack of knowledge on behalf of the unit staff nurse can lead to inconsistencies in
student assessment in the clinical setting. Evaluating students in the clinical setting can be
challenging if unit staff nurses lack formal training in the process of performing
formative assessments (Skela-Savič, & Kiger, 2015). Seurynck, Buch, Ferrari, and
Murphy (2014) identified strategies that focus on training staff nurses to evaluate student
performances, which can decrease discrepancies in faculty and unit staff assessments of
students’ performance.
Another key aspect associated with formative assessment in the clinical setting
is the use of clinical assessment tools to evaluate clinical reasoning skills of students
(Butler et al., 2011; Fahy et al., 2011; Levett-Jones, Gersbach, Arthur, & Roche, 2011).
These researchers explained that the purpose of formative assessment criteria is to
identify students’ clinical reasoning skills or lack of clinical reasoning skills in the
clinical setting. Despite this, the majority of clinical nursing staff has not been educated
in the use of clinical evaluation tools. A requirement of being a clinical staff nurse in the
medical setting includes the ability to precept students and educate students in caring for
patients, yet this is a proficiency that is rarely taught in the workplace (Burgess & Mellis,
2015; Skela-Savič & Kiger, 2015). Summative assessment allows for the evaluation of
27
the student at the end of the clinical rotation and is usually completed by the clinical
instructor with essential feedback from the staff nurse. Wells and McLoughlin (2014)
identified that staff in the medical setting are most often the first line of evaluating how
the student cares for, and understands, what is happening with the patient.
The purpose of giving feedback to the student is to improve the learner’s
comprehension, skills, or performance and ultimately impact future practice (Burgess &
Mellis, 2015). Faculty members are responsible for performing summative assessments
on the nursing student's clinical performance and the unit nurse assigned to the student
gives feedback on the student’s performance as well. Wells et al. (2014) found staff
nurses are often reluctant to give accurate feedback and assessment because they do not
want to create an uncomfortable or negative environment for the student. Student
summative assessments are fraught with discrepancies due to staff lacking training,
students rotating with multiple staff nurses, as well as staff precepting a variety of nurses
from numerous educational programs (Helminen et al., 2016). Struksnes et al. (2012)
found that clinical staff nurses deal with anxiety when given the task of assessing student
performance in the clinical setting. This fear creates an environment, which leads to
inconsistencies in how the nurse evaluates the student.
Summative assessments ensure nursing students are functioning as safe
practitioners in the clinical setting. Assessing the competence of graduating students in
nursing education is a part of creating a clinical environment conducive to safe practice
and improving patient safety (Kajander-Unkuri et al., 2014; Steven, Magnusson, Smith,
& Pearson, 2014). Tella et al. (2013) described a link between education and patient
28
safety, clearly identifying nursing students need help in connecting safe practice to patient
care and this required faculty and unit staff nurses to be able to assess students’
knowledge. Bengtsson and Carlson (2015) found that unit staff preceptors identified their
ability to evaluate nursing students as lacking objective judgment. In response to this,
unit staff nurses requested more training in the role of assessing nursing students in the
clinical setting.
Faculty and Unit Nurse Educational Levels
Faculty educational levels range from masters prepared to doctoral prepared
nurses with specialties in nursing education (Penn, Wilson, & Rosseter, 2008). In
comparison, the educational level of the unit staff nurse can range from licensed practical
nurses, associate degree register nurse, and baccalaureate prepared registered nurses
(Moscato, Nishioka, & Coe, 2013). The advanced practice nurse in the hospital system is
routinely in a leadership or advanced clinical position that is not a part of precepting
students on the floor.
Offering authentic assessments of nursing students’ clinical assignments is a
struggle for clinical staff nurses as they have no training in evaluations and may not know
how to give appropriate student feedback (Struksnes et al., 2012). Feedback obtained
from unit staff nurses lacking education in student assessment may not be consistent with
what expert faculty assess in regards to student performance. Pennbrant, Nilsson, Öhlén,
and Rudman (2013) identified that in order to develop clinical reasoning skills among
nursing students there must be qualified and educated unit staff nurse who serves as
preceptors in the clinical setting. Pennbrant et al. further acknowledged that unit staff
29
preceptors in this role would need pedagogical training appropriate to the level of student
they were precepting.
Critical Thinking
One of the biggest topics in nursing education, and on a global scale, is how to
develop and create students who can graduate and be critical thinkers in the workforce.
According to Benner et al. (2010), the new nurses entering into practice must have skills
to be safe practitioners in a variety of settings that are changing at a rapid pace. The
Quality and Safety for Nurses Institute (QSEN, 2103) and the IOM (2010) have both
identified the link to safe patient practice and nurses who can use critical thinking skills.
In a systemic review of critical thinking in nursing education Chan (2013), identified a
critical thinker is competent in the following four factors:
•Gathering and seeking information
•Questioning and investigating
•Analysis, evaluation, and inference
•Problem solving and application of theory
These four critical thinking concepts relate closely to Benner’s theory of novice
to advanced practitioner and are essential to developing clinical reasoning skills. Gaba
(2015) defined critical thinking as the ability to use intuition and individual thoughts in a
situation that one is accustomed to working in and being able to come to a conclusion.
The level of patient acuity can change at a rapid pace. Critical thinking is the
foundation for nurses to understand and use the nursing process, which is essential to
making decisions in regards to patient care (Williams & Hopper, 2015). The patient is
30
either improving or the disease process is deteriorating. The seasoned nurse relies on
years of experience to inform a high level of critical thinking. The expert nurse can help
the novice nurse develop and hone skills necessary to function in the clinical setting
(Banister, Bowen-Brady, & Winfrey, 2014). The knowledgeable nurse recognizes when a
patient’s condition changes and can respond with appropriate interventions. The ability to
quickly identify shifts in a patient’s condition and respond appropriately can prevent
adverse outcomes and prevent life-threatening medical emergencies. Marchigiano,
Eduljee, and Harvey (2011) recognized expert nursing care requires critical thinking for
clinical reasoning skills and decision-making skills. The ability to quickly identify shifts
in a patient’s condition and respond appropriately can prevent adverse outcomes and
prevent life-threatening medical emergencies (Kaddoura, 2013).
The novice nurse does not have the experience of a seasoned nurse and lacks the
development of critical thinking skills, which is required to identify the subtle changes in
a patient’s clinical condition (Jewell, 2013). Benner et al. (2010) explained one of the
goals of nursing education is to develop critical thinking skills wherein the student can
learn to look at the whole patient setting and quickly recognize the most important patient
issues as well as the least important concerns. Chan (2013) described how theory and
application in the clinical setting to develop critical thinking. Without the theoretical
background in the clinical setting, students make decisions that lack the theory of
evidenced-based practice. Without proper assessment of critical thinking, there remains a
gap in how to develop this essential skill.
31
Clinical Reasoning
Clinical reasoning is an essential mental component for nurses to make decisions
in the clinical setting and is a necessary element for providing patient care (Hunter &
Arthur, 2016). Effective clinical reasoning depends upon the nurse’s ability to collect the
right cues and to take the right action for the right patient at the right time and for the
right reason (Gaba, 2015). Clinical reasoning is the ability of a nurse to look at a large
volume of data and then correctly identify an appropriate nursing action to address the
problems identified during the assessment (Jensen, 2013; Simmons, 2010). Nurse
educators are responsible for teaching students how to respond in the clinical setting and
teaching the rationale behind the actions. Nair and Stamler (2013) defined critical
reasoning in nursing as a process that involves cognitive and affective domains of
reasoning. This type of reasoning refers to clinical judgment, clinical reasoning, and
critical thinking in nursing education.
Waters, Rochester, and McMillan (2012) identified the need for new graduates to
have the ability to manage complex patient care, which is comprised of acute and chronic
symptoms. The development of clinical reasoning skills is essential for nursing education
and must be included in learning outcomes within nursing programs (Forsberg, Ziegert,
Hult, & Fors, 2014). Russell, Geist, and Maffett (2012) described the clinical setting as an
essential component to developing clinical reasoning skills in a hands-on learning
environment that facilitates real-life decision-making.
For nursing students to develop required skills, they need exposure to many
scenarios while in school. Role modeling by the unit staff nurse helps to develop student
32
clinical reasoning skills (Johnson et al., 2012). This exposure occurs through clinical
rotations, nursing labs, and simulation. To produce graduates with clinical reasoning
skills requires faculty and unit staff nurses to have the appropriate means to evaluate
clinical reasoning of students in a consistent manner (Forsberg et al., 2014; Hunter &
Arthur, 2016). Hunter and Arthur (2016) identified that 9 out of 10 faculty members
found current assessment strategies to be inadequate and not consistent in the evaluation
of student clinical reasoning. Hunter and Arthur (2016) acknowledged that the
development of clinical reasoning is essential in the clinical setting and that unit staff
nurses largely influence the development of clinical reasoning in nursing students.
The clinical setting is a dynamic environment that involves caring for acute and
chronic patients, and working with multiple healthcare providers from different
disciplines, which creates an environment that is not conducive to allowing time for
accurate assessment of student clinical reasoning skills (Jensen, 2013). To meet the high
standards of national and international organizations calling for new graduates to have
clinical reasoning skills, preceptors and unit staff nurses need to be consistent in
assessing and teaching in the clinical setting (Lasater, 2010; McCarty & Murphy, 2011).
Ironside et al. (2014) identified the need to develop better strategies to teach clinical
reasoning skills to nursing students. Ironside et al. (2014) further identified that although
there has been a call for transforming nursing education away from being task-oriented,
there remains a gap in how clinical reasoning is taught and developed in the clinical
setting.
33
Nursing education in the clinical setting needs a focus on developing clinical
reasoning skills associated with changes in patient acuity, making decisions that impact
patient care, and development of ongoing assessment and revising care based on patient
changes (Russell et al., 2012). In this study, through the implementation of a clinical
reasoning tool, students were carefully guided through the process of clinical reasoning
and showed significant growth in their capacity to recognize changes in patient acuity.
Clinical reasoning is essential to developing nurses who are safe practitioners and who
can function in today’s complex healthcare environment.
Implications
In order to meet the call for developing nurses who can enter practice with a
sound basis of clinical reasoning skills, nurse educators must be able to collaborate with
the nurses on the floor who precept students on a one-on-one basis. The leading nursing
organizations that oversee nursing education and the IOM (2011) have called for
innovative reform in the way students are educated in the classroom and the clinical
setting.
In the literature review, I examined the importance of the clinical education
setting for nursing students to develop clinical reasoning skills (Löfmark et al., 2012).
The literature review established a lack of consistent assessments between faculty and
staff nurses, which could be linked to educational levels. Clinical reasoning and critical
thinking were identified and described laying the foundation as to why it is imperative to
develop nursing students.
34
The results from this study revealed the challenges unit staff nurses face as
pertains to assessing the performance of nursing students in the clinical setting. This led
to the development of a dedicated education unit to serve one nursing program. A
professional development workshop will be implemented to train unit staff nurses
working in the new dedicated educational units. The components of the staff development
workshop will include: (a) defining critical thinking and clinical reasoning,
(b) the use of Socratic questioning, (c) creating an educational workplace environment,
(d) how to facilitate the development of critical thinking and clinical reasoning, (e)
defining roles of faculty, and clinician instructors and student, (f) effective
communication, and (g) learning needs and goal setting as a team (Appendix A).
Training staff nurses is not easy, as nurses on the floor already feel pressured
with high patient acuity and being too busy to take on a new task. The culture on the floor
may be resistant to change and may not embrace the learning of higher assessment skills
of nursing students. The ability to include the staff nurses in making decisions in regards
to how students are assessed is significant for gaining buy-in from the staff to embrace
undergoing education to evaluate students. As a dedicated educational unit was identified
as an appropriate project, training will include linking how a dedicated educational unit
affects student clinical reasoning skills and the positive impact it has on orienting new
graduates entering practice.
The development of a dedicated educational unit and the 3-day professional
development for unit staff nurses has the potential to make a positive social impact in
nursing education by creating consistency in how critical thinking and clinical reasoning
35
skills are taught and evaluated. This can have a positive impact on a local, state, and
national level by creating nurses who possess a keen understanding and foundation of
how the clinical educational environment influences the development of critical thinking
and clinical reasoning of nursing students. This will have a positive impact on patient
safety and outcomes.
Summary
Section 1 of the proposal discussed the local problem of inconsistencies in faculty
and unit staff nurses’ assessment of nursing students’ clinical reasoning and critical
thinking ability in the clinical setting. This section outlined the rationale, specific terms
used in the study, significance of problem, guiding research questions, and a detailed
analysis of the literature review related to the problem. Lastly, implications of this study
were described.
Nurse educators working alongside unit managers and unit staff nurses face new
challenges in the management of complex diseases. Developing new teaching strategies
that are unique and promote critical thinking require input from all parties to ensure that
these strategies evolve into a comprehensive nursing practice (Marchigiano et al., 2011).
Although there are multiple tools to assess competencies, they are often inadequate and
lack appropriate identification of where performance can be improved (Zasadny & Bull,
2015).
The need for nursing students to have clinical reasoning and critical thinking
skills is well documented, yet how faculty and unit staff nurses assess these attributes
remains elusive. Although the level of patient acuity continues to increase and the health
36
care system is evolving and changing at a rapid speed, there remains a gap in how to
teach clinical reasoning skills, but also how to assess these skills. The clinical
environment remains the best setting for students to develop these skills as they are
exposed to a diverse patient population that range from wellness to the very sickest. In
this environment, students are actively involved with patient care and are a part of the
team performing direct patient care.
There is a documented difference between levels of education in regards to
faculty and unit staff nurses. The nursing faculty members have additional training that
directly addresses teaching and assessing of students in the clinical setting whereas the
unit staff nurse has the expertise to care for patients but lacks education in teaching and
assessing nursing students. Understanding how faculty and unit staff nurses assess
clinical reasoning skills is vital for determining how the future of nursing education
evolves in the clinical setting (Raines, 2012). Section 2 provides a description of the
research design and methodology used for this study.
37
Section 2: The Methodology
Introduction
In the 21st century, nursing education must focus on developing the clinical
reasoning skills of nursing students (Holland & Ulrich, 2016). Clinical reasoning is
associated with safe clinical practice and is a fundamental skill that all nursing students
must begin to develop while in nursing school. The purpose of this qualitative case study
was to explore the ability to evaluate students’ critical thinking and clinical reasoning
skills in the clinical setting from the perspectives of faculty and unit staff nurses who
served as preceptors in a BSN nursing program in a large metropolitan hospital.
Creswell (2007) described qualitative research as exploring the perceptions and
experiences of people by using structured face-to-face interviews, group interviews, and
surveys, as well as direct observations. I used semistructured face-to-face interviews to
explore the perceptions of faculty and unit staff nurses in regards to the assessment of
clinical reasoning skills of nursing students in the clinical setting. Broad and open-ended
research questions were posed to focus the study and, at the same time, remain open to
what emerged from the data (Bogden & Biklen, 2007). The following research questions
were addressed in this study:
RQ1. What are faculty and staff perceptions concerning the level of
preparedness staff nurses need to assess critical thinking and clinical
reasoning ability of nursing students in the clinical setting?
38
RQ2. How do the medical-surgical faculty members describe their process of
evaluating the critical thinking and clinical reasoning skills of nursing
students in the clinical setting?
RQ3. How do unit staff nurses describe their process of evaluating the critical
thinking and clinical reasoning scores of nursing students in the clinical
setting?
The subquestions that guided the development of the interview questions (Appendix B)
were:
1. What do faculty and unit staff nurses perceive as training needs for
overcoming barriers to assessing students in the clinical
setting?
2. How comfortable are you assessing clinical reasoning of nursing students
while they are in the clinical setting?
3. How do faculty and unit staff nurses explain the reason for assessing
critical thinking and clinical reasoning of nursing students in the clinical
setting
4. What are barriers to assessing nursing students clinical reasoning in the
clinical setting?
5. How do faculty and unit staff nurses describe critical thinking and clinical
reasoning and why are these skills important for students in the clinical
setting?
39
The primary goal of this study was to explore how faculty and staff assess critical
thinking and clinical reasoning skills of nursing students in the clinical setting. Through
this process, strategies could be further aligned and developed to assess student clinical
reasoning as well as impact on how clinical reasoning can be taught in the clinical
setting. Qualitative research yields thoughtful and relevant findings that have the
potential to affect education and influence how decisions are made in a variety of settings
(Lewis,
2015).
Research Design and Approach
A descriptive case study was used to explore the experiences faculty and unit staff
nurses described in assessing students’ ability to think critically and use clinical
reasoning skills in the clinical setting. A case study is used to discover meaning or gains
insight or understanding of an individual or group or situation (Lodico, Spaulding, &
Voegtle, 2010). This was a bounded case study as it explored the interactions of one set of
faculty and one set of unit staff nurses’ interactions with nursing students in one specific
hospital. A bounded case study specifically sets the place and physical boundaries in
which the study is centered (Creswell, 2012). The descriptive case study allows a
researcher to look at patterns of behavior and, from this insight, gain a better
understanding of how critical thinking and clinical reasoning of nursing students is
assessed in the clinical setting by faculty and unit staff nurses. Descriptive case studies
allow for the exploration of a person or a group’s thoughts and perceptions (Creswell,
2012).
40
Several other types of studies were considered and ruled out as not suitable for
this study. Specifically, ethnography was considered but ruled out as it has a focus on
culture (Creswell, 2012). Although there is a culture to nursing, this was not the purpose
of this study. Another study design that was not chosen for this study was grounded
theory research. A grounded theory research study is used to explore a particular theory
and help to modify or develop the theory in some manner or form. The intention of this
study did not include exploring a specific theory, but rather exploring perceptions of
individuals. A quantitative approach was rejected, as it is unable to gather rich
descriptions of feelings, thoughts, and perceptions of an individual or group, which was
needed to best answer my research questions.
Participants
The site for this study was a metropolitan area baccalaureate program, comprised
of 80 to 120 nursing students who participated in medical-surgical clinical placements
each semester (School of Nursing, 2015). The school attracted students from all over the
nation and offered a fast track program that can be completed in 16 months for students
pursuing a second-degree. The program had no cap on the number of students entering
the program, meaning if the student met all the prerequisites and qualified with the
mandatory GPA, he or she was allowed to enter the program. The large amount of
students entering the program was significant to the study as this program graduated
twice each year a large number of nursing students who entered nursing practice. The
new graduates needed to have a solid basis of clinical reasoning skills when entering a
dynamic healthcare setting (Watt, & Pascoe, 2013).
41
The purposeful sample was derived from multiple Adult I and Adult II
medicalsurgical clinical faculty and unit staff nurses associated with a baccalaureate-
nursing program. Adult I and Adult II medical-surgical clinical experiences are the
second and third clinical rotations in which the student works under the direct supervision
of a registered nurse caring for patients in a clinical unit based within a hospital. The
medicalsurgical faculty member accompanied students into the clinical setting and
oversaw student preparation and participation with the unit staff nurse during the
assigned clinical rotation on a medical-surgical floor. The unit staff nurse was an RN who
precepted a nursing student for an assigned daily clinical rotation and the student nurse
worked with this registered nurse (RN) to provide direct patient care. The student may
have worked with the same assigned RN or may have been assigned a new RN each
week. The inclusion criteria to be selected for the pool of potential participants was to be
a licensed RN, and either faculty that taught in the clinical setting or a unit staff nurse
who precepted students on a medical-surgical unit within the hospital. In the state where
the study was conducted, an RN is prepared at either the associate or baccalaureate level.
There was no distinction in rank or pay and both levels of educationally prepared RNs
had the title of staff nurse.
Creswell (2012) defined purposeful sampling as intentionally selecting where the
research is conducted as well as the participants for the study as this allows for specific
insight to a particular phenomenon. Purposeful sampling involves choosing specific
participants that are integral to the study based on their connection and involvement to
the study. There was a purposeful sample of unit staff nurses selected from a mix of
42
medical-surgical units associated with a hospital in a large metropolitan city. A
purposeful sample of six faculty and six unit staff nurses participated in the descriptive
case study. Arcury and Quandt (1999) described purposeful sampling will ultimately
reflect the intent of the study and allow the researcher to choose participants who have
the potential to represent characteristics that are representative of the study. Creswell
described a small sample as being appropriate to gain an understanding of a specific site
or representative of a group of individuals.
Access to Participants
University and hospital Institutional Review Board (IRB) approval was obtained
before IRB approval was sought from Walden. Formal approval was granted from the
Walden IRB before any data were collected. The Walden IRB approval number for this
study is 09-12-16-0443582. Once IRB approval was given, the Associate Dean of the
School of Nursing was contacted to gain access to potential faculty participants. The
hospital IRB approval was obtained before contacting potential unit staff nurses. The
hospital education department served as a gatekeeper to identify appropriate clinical units
from which to recruit potential unit staff nurse participants. A hospital IRB approved
flyer was distributed by the researcher to recruit potential participants from the clinical
units.
With qualitative research, there always exists a possibility of an ethical dilemma
in how a researcher acquires access to research participants, which can influence how
participants respond to the investigator (Holloway, & Wheeler, 2013). For the purpose of
this study, the dean of the nursing department was contacted to help identify faculty who
43
met the inclusion criteria from each organization. The e-mail was used to explain the
study to both faculty members and unit staff nurses. A purposeful sample was then
chosen from a pool of volunteers at each location. The faculty participants were from the
school of nursing located within the university and unit staff nurse participants were RNs
employed at the hospital. Medical-surgical faculty and unit staff nurses were assigned in
both the fall and spring 16-week semesters; study participants were from one semester.
Researcher Participant Working Relationship
I had no authority over any of the participants. Interviewing participants required
that I establish contact with individuals who I may or may not have had previous contact
with (Seidman, 2013). Houghton, Casey Shaw, and Murphy (2010) explained that a
researcher should reinforce to study participants that they should feel no coercion to
participate in the study, and I reiterated that the participants could withdraw consent to
participate at any time.
Ethical Considerations
Once participants were identified, I gave participants a consent form in person to
review before the study began. They were given a consent form that also served as an
invitation to participate in the study. The consent form provided details about the study,
reinforced that participation in the study was voluntary, and identified that participation
was confidential. The consent form explained that all individual identities were protected.
After the individual read the consent form and any questions he or she posed were
answered, the participant was asked to sign the consent form. It was explained to each
participant that by signing the consent form, he or she acknowledged an understanding of
44
the protection the consent form provided. I reinforced that all responses would be coded
so no identifying elements remained. All data are stored in a locked file cabinet within
my office that only I have access to. A back-up copy of collected data is in my home in a
locked safe that only I have access to. Documents will be stored for 5 years as required
by the Walden University IRB. No data from this study will be used for any purpose
outside of this research study. After 5 years, the data will be shredded and disposed of
with a licensed shredding company.
Data Collection
Semistructured Interviews
The structured interviews allowed me to ask questions that solicited rich
descriptions and allowed for additional clarification, and probing questions to be posed to
fully gain the participants’ perspective. Participants were assigned a unique identifier,
which was denoted on the transcript. A series of open-ended questions (Appendix B)
were used during the individual interview sessions. Both the faculty and unit staff nurses
answered the same questions. Interviews were conducted with faculty members from the
university and unit staff nurses from one hospital. Open-ended questions were prepared
to explore participants’ thoughts and perceptions (Creswell, 2012). Field notes were also
hand written during the interviews and compared to the transcribed data. One-on-one
interviews were conducted in a location convenient to the participants. Interviews were
recorded for consistency and to ensure reliability. Before the interviews, an expert panel
of three to four faculty and unit staff nurses outside of the research participant pool
reviewed the questions to screen for bias issues and assess whether the questions gave an
45
adequate range of responses (Chenail, 2011). The criteria to be an expert reviewer were a
unit staff nurse who had 5 years or more of medicalsurgical experience who worked with
students in the clinical setting, and faculty
members who taught medical-surgical courses and had experience supervising students in
the clinical setting on medical-surgical units. Member checking requires interview
participants to validate the transcripts after the interviews are transcribed (Koelsch,
2013).
The individual interviews took place in a facility conference room that was in a
private setting or in a faculty member’s private office space or any such place that the
participant found convenient. The unit staff nurse interviews took place in a reserved and
private conference room located within the hospital or within private office spaces. I
suggested a place that was quiet and without distractions. Once the consent form was
signed, interviews took place at times that were convenient to participants. Permission
was obtained to record and collect the responses during the interviews. Individual
interviews allow for insight into personal perspectives and gauge the experiences and the
overall atmosphere of an instructional setting (Barlish & Sullivan, 2012). Interviews
lasted from 45 to 60 minutes and participants were only scheduled for one interview.
Transcribed data were assigned a letter corresponding with either faculty or staff nurses
and stored in a binder locked in a file cabinet. The interviews were separated into sections
for unit staff nurses and faculty. Hand written field notes were assigned the same
corresponding letter and filed with the transcribed interviews. No clarification or
46
additional information was needed after the first transcript was reviewed, and no
additional interviews were required.
Gaining Access to Participants
I used an interview protocol to guide the interview sessions (Appendix C). The
interview protocol ensured at the beginning of the interview that I discussed critical
details about the study and explain informed consent (Jacob & Furgerson, 2012). I asked
the participants if they had any questions and provided detailed answers before they
signed the informed consent. Participation was voluntary and participants could choose to
withdraw from the study at any time prior to completion of the individual interviews
without fear of reprisal. The consent form identified in writing that participation in the
study was in no way linked to job performance and evaluation.
Role of Researcher
I had been an employee at the university where I interviewed faculty. I was not
currently employed at the university where faculty were asked to participate in the study.
I currently teach nursing education in another baccalaureate institution with no affiliation
with the university where the research was conducted. I had no existing work
relationships with any potential participants within the university setting. I have taken
students into the clinical setting where unit staff nurses were selected for study
participation; but, I was never an employee of this facility. In both locations, I did not
have any supervisory role or authority over faculty in the academic setting or nurses in
the hospital. As a faculty member who had experience in evaluating students’
47
performance in the clinical setting, I had to be diligent about remaining free of bias
during question development and the semi structured interview process (Lewis, 2015).
Data Analysis
Phase 1 of data collection involved identifying who, what, when, and where data
was collected. This stage included the audio-recorded responses being transcribed into
text data. The printed transcripts were e-mailed or hand delivered back to the participant
for member checking to confirm that the thoughts and statements of the data were
accurate (Creswell, 2012). Participants had 3 days to make any changes they desired to
the transcript. No response from any participant was received after 3 days, and it was
assumed no changes were desired. Once member checked, I sorted, coded, categorized,
and analyzed the data.
Phase 2 was associated with hand coding the data and the transcribed interviews
were broken into smaller sections and identifiable descriptive terms were picked out
which led to identifying the emerging themes (Creswell, 2012). Segments of the text
were bracketed and assigned labels of setting, perspectives, strategies, barriers,
experiences, resources, examples, expectations, and suggestions. In Vivo coding was then
used to further delineate participants’ actual words (Creswell, 2012). These coded data
sets were reviewed and read over numerous times while I made notes and identified
recurring themes.
In the next step, Phase 3, I began to extract the major themes or ideas from the
coded sections, identifying five to seven themes recurring in faculty and unit staff nurses’
interviews (Creswell, 2012, p. 245). The data were then analyzed to look for overlapping
48
themes. When considering data analysis, Elo et al. (2014) identified trustworthiness as
being closely related to how data are collected and deciphered and coded with a reliable
and valid method. These five to seven themes were identified, highlighted, and were
coded with descriptive terms as this process helps identify categories (Creswell, 2012).
The final step in data analysis included a comparison and contrast between faculty and
unit staff nurse themes. Coded data had no identifying information and was only linked to
a participant by a code. No identities or facilities were revealed while the study was being
conducted or when the report was compiled.
Table 1
Data Analysis: Phases of Qualitative Data Analysis
Phase 1
a. Describing data: who, what, when, and
where
Initiated before each interview
b. Transcribing Interviews transcribed within one week of
interviews
c. Member checking
Phase 2
Transcribed interviews returned to
participants within 1 week after interview
is conducted
a. Open coding: Identifying themes
Phase 3
Emergence of findings, initiated after
member checking
a. Coding: Looking for repeating themes
Phase 4: Final step
Begins with initial review of findings,
reviewed every two interviews
a. Comparison: Comparing final themes This is done as the final step and will
compare and contrast the final identified
themes between staff RNs and faculty
49
Evidence of Quality
Within 7 days after interviews were transcribed, I submitted them back to the
participants for member checking. Participants had 3 days to review and return the
transcribed interviews. If transcripts were not returned, it was assumed that no changes to
the document were desired by the participant. Triangulation of data consisted of using
two sources for data collection. For the purpose of this study, the two sources were semi
structured interviews with both faculty and unit staff nurses. As a researcher, I was aware
of my personal biases. I had interview questions reviewed by the expert panel before they
were used in the study to assure that the questions were open-ended and reflected the
guiding research questions Additional attention was paid to having a neutral demeanor in
all of my physical actions during the interviews.
Discrepant data are data that conflict with the overall findings in a research study
(Creswell, 2012). In order to avoid bias it is necessary to identify discrepant findings that
are outside of identified themes. Discrepant data can offer unexpected insight and,
although singular in nature, can sometimes help to clarify certain themes (van Gennip,
Pasman, Oosterveld-Vlug, Willems, & Onwuteaka-Philipsen, 2013). These were
identified in the study and noted in relation to the identified themes. Contradictory data
can also be used to identify perceptions that need further exploration by a researcher
(Merriam, & Tisdell, 2015). I was objective in analyzing discrepant findings and
discrepancies identified in the study were discussed.
50
Limitations
The methodological limitations associated with this study included participant
limitations and transferability of the findings. The study was limited to faculty who
taught clinical experiences on medical-surgical units and unit staff nurses who precepted
students on medical-surgical units. Additional limitations included purposeful sampling
of faculty from one university institution and unit staff nurses from one hospital. A
limitation of any qualitative study is the ability to generalize the findings to a broader
population. This study was bounded to one population and setting and the reader can
decide whether or not the findings are transferable to other settings (Marshall &
Rossman, 2014). As semistructured interviews were used to gain participants’ perceptions
of previous events, there remains a limit to how accurate and detailed the responses
represent prior experiences (Berge, Loth, Hanson, Croll-Lampert, & NeumarkSztainer,
2012). Further limitations were discussed after the study was completed and the project
was identified and described.
Data Analysis
Once IRB approval was established by both research sites and Walden University,
I began to prepare to conduct research. There was a purposeful sample of unit staff nurses
selected from a mix of medical-surgical units associated with a hospital in a large
metropolitan city. A purposeful sample of six Adult I and Adult II medical-surgical
faculty from the school of nursing were also chosen to participate in the study. Once
participants were selected they were either hand delivered a consent form or emailed a
consent form for review, and a time for an interview was scheduled. Once interviews
51
were scheduled the consent form was reviewed and the interview procedures were
explained, risks and benefits of participating in the study were discussed, and the consent
form was signed. Permission was obtained to record and collect the responses during the
interviews. I used an interview protocol to guide the interview sessions (Appendix C).
Data Analysis Results
The data were obtained via semistructured interviews and then transcribed prior to
beginning the process of coding (Creswell, 2012). After transcription, the documents
were submitted by email back to participants for member checking to verify that the
statements accurately reflected participants’ thoughts and transcribed data were correct
(Creswell, 2012). Participants were given 3 days to review data and no responses from
participants verified there were no desired changes to the transcribed documents. Once
member checked, I began to sort, code, categorize, and analyze the data via color coding.
The data were then broken into smaller sections and the themes were identified and
labeled.
In Vivo coding was then used to identify sections of the transcripts that
represented the major themes (Creswell, 2012). I developed narratives of the participants’
viewpoints once the data had been broken into themes and I used supporting quotations
from the interviews to support these themes. I then compared the faculty and unit staff
nurses’ interviews and comprised the final six themes that accurately represented both
groups. These final themes were then contrasted and compared between faculty and unit
52
staff nurses. A well written qualitative study uses rich descriptions derived from
participants to support and validate the researcher’s conclusions (Bogdan & Bilken,
2007).
Findings in Relation to Problem
The purpose of this qualitative case study was to explore the ability to evaluate
students’ critical thinking and clinical reasoning skills in the clinical setting from the
perspective of both the faculty and unit staff nurse. Twelve participants were asked to
participate in semistructured interviews over the course of 4 days. An interview protocol
(Appendix C) was used to help gather demographic information and the interview
questions (Appendix B) with guiding subquestions were used to gather participant
perceptions. When further clarification was needed during the interviews, additional
questions were used to help clarify participant responses.
Faculty interviewees were very direct and detailed in explaining how critical
thinking and clinical reasoning of nursing students was assessed in the clinical setting. In
contrast, the unit staff nurses often gave illustrations and examples of basic clinical skills
in regards to how critical thinking and clinical reasoning of students was assessed.
Faculty and staff interviews revealed barriers to assessing students, a lack of consistency
in definitions of critical thinking and clinical reasoning, and needed resources for
educating nursing students in the clinical setting. Faculty and unit staff nurse interviews
revealed in rich detail expectations they had for students in the clinical setting.
Individuals who were interviewed expressed a variety of reasons as to why there
were inconsistencies in how students were taught and assessed in the clinical setting.
53
Faculty and unit staff nurses both expressed that the identified clinical inconsistencies
needed more than just additional staff training. Both faculty and unit staff nurses
acknowledged that students needed more consistency in where and how long students
were assigned to clinical units. The unit staff nurses discussed how it would be easier to
work with the same students on the unit consistently to develop trust and rapport with the
student in order to better facilitate critical thinking and clinical reasoning. Faculty stated
having students in multiple locations was not conducive to facilitating learning and
rotating facilities and clinical units made it very hard to encourage relationships with staff
and develop an environment beneficial to teaching students. Overall, the consensus of the
participants in the study agreed there was a need for the school of nursing and the
hospital to develop a partnership to move forward with a dedicated educational unit. To
facilitate this, a 3-day professional development program has been created for unit staff
nurses in order to better prepare them to facilitate student success in the clinical setting.
Research Questions
The following research questions were used to guide the data collection:
RQ1. What are faculty and staff perceptions concerning the level of preparedness
staff nurses need to assess critical thinking and clinical reasoning ability
of nursing students in the clinical setting?
Research Subquestion 1: What do faculty and/or unit staff nurses perceive as
training needs for overcoming barriers to assessing students in the clinical setting?
Interview Question 1. Describe the resources needed available to evaluate
students in the clinical setting?
54
All of the faculty participants expressed that utilizing a dedicated educational unit
was needed to better facilitate teaching in the clinical setting. One faculty member
described the clinical units as “not conducive to the staff nurse being able to teach…
because of time constraints and the volume of student rotating through the unit” (Faculty
D). Faculty and staff identified that a clinical evaluation tool would create consistency
between faculty and unit staff nurses when assessing critical thinking and clinical
reasoning. Additionally, staff explained that they “rarely” (Unit Staff Nurse A) take part
in formal evaluations of medical-surgical patients. The following response was typical of
all staff nurse participants. “I wouldn't say we have a formal evaluation. An informal one
would be I usually try to interact with students, just to give them confidence as they are
learning. I wouldn't say anything formal” (Unit Staff Nurse D). Staff did
communicate that having an assessment tool would make it easier to provide feedback to
faculty and provide performance feedback to the student. Responses included:
Some people do bring a thing that said, "Was I professional? Did I come on
time?" All of those things, "Was I engaged?" I guess and a few of them have in
the past… little things like that…you check mark and then sign your name and
they give it back to their instructor but most, I don't think lately any (students
have brought anything like that) but it would be beneficial to provide feedback.
(Unit Staff Nurse E)
“Yes, having a way to communicate with the student and help them to think thru the
disease process would be helpful” (Unit Staff Nurse A).
55
As a group, the faculty communicated that in order for there to be a more
balanced teaching and assessment environment, the unit staff nurses would need
additional training in how to develop the critical thinking and clinical reasoning skills of
students. The following response was typical of all faculty participants:
I think it would be very helpful if we could get some type of tool and work
together with the particular nursing unit that we're going to be on. Then, we
would have something that we can actually talk to the nurses about because right
now, we ask the nurses, "Okay, how's the student doing?" They'll say, "Oh, they're
doing great." Sometimes the nurses come up and just volunteer that information,
but I don't know what they're measuring. (Faculty B)
“The other thing is that a really good clinical nurse a lot of times is not the best teacher as
they don't have the education to be able to teach” (Faculty A). “When I walk by the
nurses, if I ask how they are doing, ‘Oh, they are doing really good.’ That's pretty much
all I hear, no explanation really…ever” (Faculty C).
Interview Question 2: What are your suggestions for staff and/or faculty training
in the evaluation of students in the clinical setting?
All of the staff nurses, with the exception of one staff nurse who had previous
training in precepting leadership students, agreed that training would be beneficial.
Specifically, the focus of training should be on the facilitation of learning experiences for
nursing students while on the clinical units. The unit staff nurses identified time and
incentives as needed resources in regards to additional training. Responses included: “We
56
don't really do that. We don't really evaluate them during the day. If we did have training,
it would certainly make sense” (Unit Staff Nurse E).
I wouldn't say we have a formal evaluation. An informal one would be I usually
try to interact with students, just to give them confidence as they are learning. I
wouldn't say anything formal. Yes, training would be beneficial if we have time
and incentives. (Unit Staff Nurse D)
Faculty responses indicated the focus of training should be on the facilitation of
learning experiences for nursing students while on the clinical units. The faculty
unanimously agreed that training for the unit staff nurses is very important and there is a
distinct lack of unit staff nurses’ ability to provide feedback to faculty about the students’
ability to think critically or clinically reason. They further identified the importance of
developing dedicated educational units where the culture would be one of embracing the
educational process of nursing students. Additionally, faculty described incidences where
they always have to ask for feedback about student performance but rarely get anything
but generic feedback by stating:
If I do get feedback. It is only if I go and ask for it. A lot of times, I'll just stop by
the nurse when the student is not around and just ask how the student is doing.
Usually in that circumstance, I get really positive feedback but very generic.
They're doing really good or they're a hard worker. (Faculty D)
“I personally think that every nurse who is going to be a preceptor and going to help with
student learning should have all their nurses trained to be able to facilitate student
learning” (Faculty C).
57
Interview Question 3: What are your views on having an evaluation tool to
evaluate clinical reasoning?
All of the faculty agreed that a formal way to evaluate critical thinking and
clinical reasoning of nursing students could make a significant impact and improve
student learning in the clinical setting. However, many reiterated that it would take
training to accomplish this as well as having clinical units that embrace the paradigm of
teaching. Responses included:
I think (the nurses need) a way to openly evaluate the students on understanding
the disease process and how it could (the disease process) potentially affect the
patient including labs and medication, if a nurse isn't willing to educate or doesn't
know how to educate a student, often you'll see a student that can just get by in
clinical without ever having to discuss labs and meds and how they can really
effect the patient. The nursing instructor should also be doing that with the
student but the nursing instructor doesn't know everything about the patient like
the nurse does. (Faculty D)
I think, in my opinion, that that would objectify the process, that it would keep it
(assessment of students) consistent. I believe it needs to have input from
curriculum committees, even hospital committees I think (we need to) work
together. (Faculty A)
Well, not all nurses are receptive to having students and you can't force that I
don't think. I believe those nurses who are receptive to having students need to be
the nurses that the students are going to follow. I think that those nurses need to
58
have some training on what we're looking at and what we're actually measuring to
make sure that the students are connecting the dots. (Faculty B)
The unit staff nurses felt that having a tool to evaluate clinical reasoning could
positively impacts how clinical reasoning of students is assessed. They also thought it
could help them (nurses) be more predictive about what patient care they allowed the
student to perform. Responses included:
I think it's necessary. Clinical reasoning is something that is built over time. That's
why I said it's so flexible. There's not a specific thing you can say, ‘Okay learn
this’…a tool would be helpful to identify (patient) trends… Seeing things that are
critical to the patients. All information of a patient is important, but not
everything is pertinent at that moment for the patient. (Unit Staff Nurse D)
“If we had a tool, when they can prove to me that they've got some knowledge I
(would) certainly feel more comfortable giving them a little more leeway and allowing
them to perform more patient care” (Unit Staff Nurse E)
Interview Question 8: If you had a tool to evaluate clinical reasoning of nursing
students, what would you like to see included on this tool?
The unit staff nurses agreed that a tool would allow them to take a more active
role in assessing the Adult 1 and Adult II medical-surgical students in the clinical setting.
The perspective of the entire faculty interviewed agreed that being able to have consistent
and structured feedback from the unit staff nurses would help establish a foundation of
critical thinking and clinical reasoning skills of the medical-surgical nursing students.
The faculty described teaching strategies and concepts that would help students link
59
critical clinical pieces together and facilitate clinical reasoning. Faculty Participant D
stated:
I think a way to openly evaluate the students on understanding the disease process
and how that could potentially affect the patient including labs and medication, if
a nurse isn't willing to educate or doesn't know how to educate a student, often
you'll see a student that can just get by in clinical without ever having to discuss
labs and meds and how they can really effect the patient. The nursing instructor
should also be doing that with the student but the nursing instructor doesn't know
everything about the patient like the nurse does.
RQ2. How do the medical-surgical faculty members describe their process of
evaluating the critical thinking and clinical reasoning skills of nursing
students in the clinical setting?
RQ3. How do unit staff nurses describe their process of evaluating the critical
thinking and clinical reasoning scores of nursing students in the clinical
setting?
Research Subquestion 2: How comfortable are you assessing clinical reasoning of
nursing students while they are in the clinical setting?
Interview Question 4: What is your experience with students in the clinical
setting, please give me a few examples of what a day with nursing student in the clinical
setting is like.
A staff nurse described working with the nursing student in performing hands on
patient care and referred to the student as being an “extra hand” (Unit Staff Nurse C).
60
Another unit staff nurse described how it took time during the initial introduction to the
student to identify what semester student she was working with and if the student was
from an associate or baccalaureate program. One unit staff nurse participant described
how it was difficult to identify what level of student she was working with from day to
day. This perspective was reiterated by almost all of the interviewed unit staff nurses. In
contrast, the faculty gave a very detailed example of what a clinical day looked like from
the start to the finish including examples of how critical thinking and clinical reasoning
was facilitated. Participant responses included: “I don’t ever know what level of student I
have been assigned. It is confusing and takes time out of the day” (Unit Staff Nurse D).
“We need more nurses so it's a good feeling when you're able to teach them, but it
(precepting a student) does really make you work extra hard (Unit Staff Nurse C).
In comparison, the faculty were very unified in describing how each clinical day
began with scholarly preparation for patient care as evidenced by the following
responses:
We start out with preplanning and we do a pre-conference, talk about what our
goal is for the day, maybe how the flow of the day is going to go, what my
expectations are related to the objectives of the clinical and of the clinical week,
then they go and they take report from their nurse that has the patient that they're
assigned to. (Faculty A)
We start talking about the patient diagnosis. They are required to do a
pathophysiology tree that discusses what the patient's problem is and the expected
outcomes. We connect the expected outcomes with what their patient is
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presenting. Then we start going through labs and medications. I generally will
just ask the students information that could make them think (Socratic
questioning) and help connect the dots. (Faculty D).
Interview Question 5: Please describe your comfort level when interacting with
students in the clinical setting.
There were not any study participants that alluded to being dissatisfied with
interacting with students in the clinical setting. The faculty expressed satisfaction with
teaching in the clinical setting and being very comfortable with students in the clinical
environment. All unit staff nurses in this study were supportive of having students
assigned to them in the clinical setting. However, the study did reveal that one of the
barriers that occur for faculty is having students assigned to clinical staff who do not want
to precept students. Supporting this finding are select quotations from the participants:
I am very comfortable with students in the clinical setting. I have a passion for
working with them in the clinical setting because I also work in the didactic part
so I like to see those pieces come together. (Faculty A)
“I’m very comfortable with interacting with nursing students in the clinical setting” (Unit
Staff Nurse B).
Research Subquestion 3: How do faculty and unit staff nurses explain the reason
for assessing critical thinking and clinical reasoning of nursing students in the clinical
setting?
Interview Question 6: Describe how critical thinking influences a student’s role in
the clinical setting?
62
In discussing critical thinking and clinical reasoning related to nursing students
there were distinct differences among faculty and unit staff nurses. Faculty described
critical thinking as the foundation to the nursing process and how it was introduced in the
first nursing courses. They further explained that it related to skills and medications, and
life experiences. There was an example that critical thinking was a must have skill in
nursing as pertained to being able to “think through situations” (Faculty C). Staff also
thought critical thinking evolved through life situations and that it was an essential skill
nurses needed in order to function in their professional role. Responses included:
“They're (nursing students) just thinking about situations and maybe trying to problem
solve or they're thinking through processes. It doesn't necessarily have to do with a
patient outcome or an intervention” (Faculty F). “It's important because that's what the
life of a nurse is. They have to be able to discern between what's priority, what can be
delegated” (Faculty A). “I think their critical thinking makes them (student) ask questions
and maybe makes them (student) curious in how things correlate” (Unit Staff Nurse F).
Interview Question 9: Please describe some examples that involve you and
clinical reasoning while working with a nursing student in the clinical setting?
The faculty excelled at facilitating and describing clinical reasoning and how to
teach this skill to nursing students. For example, there was numerous examples of tying
theory to practice, and identifying differences in how patients can present with the same
disease process and helping the student work through a variety of clinical scenarios. In
contrast, unit staff nurses would describe a task and identify if the student could perform
skills correctly or correlate clinical reasoning with simple tasks such as, identifying side
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effects of medications. Both of these skills are important to nursing education but are
knowledge based and do not utilize higher order level of thinking skills associated with
clinical reasoning. The unit staff nurses stressed time constraints and not always knowing
the performance level of the student they were working with as a limitation to teaching
clinical reasoning. This is evident in the following responses:
Clinical reasoning is taught by … Socratic questioning and teaching there at the
bedside and drawing inference from other patients they have had previously…
Last week you had a diabetic patient as well… this week you have a diabetic
patient, but what looks different about them and why are we treating them
different? Yes. Connecting the dots continuously. (Faculty A) We start talking
about the patient diagnosis. They are required to do a pathophysiology tree that
discusses what the patient's problem is and the expected outcomes. We connect
the expected outcomes with what their patient is presenting. Then we start going
through labs and medications. I generally will just ask the students information
that could make them think and help connect the dots. (Faculty B)
“I ask them if have ever they done the skill you know, because certain facility and schools
have different kinds of products. I will walk them through it, kind of get them
comfortable with the supplies” (Unit Staff Nurse C).
Interview Question 10: Please describe what your expectations are for students in
the clinical setting?
All but one person interviewed described having set expectations for nursing
students in the clinical setting. All participants stated they expected students to be
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“conduct themselves professionally” (Unit staff nurse E and Faculty C). Other responses
were: “I expect professionalism. Professional behavior, professional look, and
appearance. I expect that they will be self-motivated to seek out learning opportunities”
(Faculty E).
One is professionalism that they behave in a way that they should. Two is
transpersonal caring behaviors and relationships based on Jean Watson's Model of
Caring and human caring science. Safety and competency. That they come
wanting to learn something and they come not afraid to get their hands dirty.
(Unit Staff Nurse F)
Interview Question 11: In your opinion what constitutes a successful day with
students in the clinical setting?
Both faculty and unit staff nurses wanted students who were active participants in
their learning experiences while attending clinical rotations. Both also expressed the
importance of the clinical experiences focusing on safe patient practice and developing
nursing students with a high regard for patient safety. This is evidenced in the following
responses: “A student that is willing to jump in. A student with a good attitude that wants
to learn and ask a fair amount of questions” (Unit Staff Nurse B). “Ultimately, I think that
if a student can care for a patient and understand what's going on with that patient,
making some sort of connections to their pathophysiology, lab work medication and
anticipate needs, I think that's successful” (Faculty C). “No bad events with the patient,
obviously. SAFETY. I feel like I’ve taught them (students) something, or they’ve learned
something and if I can find them a skill they want to try” (Unit Staff Nurse E).
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Interview Question 12: What is your involvement in the evaluation of students
during a routine clinical day?
All of the unit staff nurses stated they had no involvement in the evaluation of
Adult I and Adult II medical-surgical students doing clinical rotations within their units.
One unit staff nurse referred to one school of nursing within the region as having an
evaluation tool. However, the unit staff nurse was unable to recall what the tool evaluated
in regards to student performance. In contrast, all of the faculty members were able to
describe how they assessed nursing students at the beginning (preconference) of the
clinical day, during the clinical day, and at the end (post conference) of the clinical day as
stated below:
I use Socratic questioning and teaching at the bedside. I even try to draw
inference from other patients that they’ve had during previous (clinical rotations).
Last week you had a diabetic patient as well…This week you have a diabetic
patient but what looks different about them and why are we treating them
different? Yeah. Connection of those dots. (Faculty A)
“We don't really do that. We don't really evaluate them during the day” (Unit Staff Nurse
C). “I wouldn't say we have a formal evaluation. An informal one would be I usually try
to interact with students, just to give them confidence as they are learning. I wouldn't say
anything formal” (Unit Staff Nurse D).
When faculty was asked about getting feedback from the unit staff nurses in the
clinical setting faculty stated they received “little to none” (Faculty B). They further
clarified if they received feedback about student performance it was generally very
66
generic and very general in nature, and was often positive feedback related to “good help
today” (Faculty B), or “they did well today” (Faculty C). One respondent stated: Usually
the only time I hear from a staff nurse is if I address them directly because I have
something I want to discuss with them regarding the student or if they have a concern or
a problem with a student” (Faculty D).
Interview Question 13: How does a student’s ability to use clinical reasoning
impact the clinical experience?
Faculty were very clear in formulating how clinical reasoning is needed to make
connections between theory and application. Furthermore, faculty gave examples of
facilitating the development of clinical reasoning and how, without the development of
this skill, the student not progress towards safe nursing practice. They faculty further
described how clinical reasoning impacts learning and interactions with unit staff nurses
in the clinical setting: “If they (staff) see a student capable of critical thinking or clinical
reasoning, they allow them to have more autonomy and take more initiative in that
patient’s care. It's like there's that trust there” (Faculty E).
Critical thinking and clinical reasoning and initiative are two of the biggest things
that impacts our clinical environment. Whenever they see a student that is actively trying
to learn new processes, one that is asking questions, one that wants to be there and they're
not just there checking off a certain amount of hours, that's when we see a buy-in from
our staff, from our hospital members. (Faculty F)
Research Sub Question 4: What are barriers to assessing nursing students clinical
reasoning in the clinical setting?
67
Interview Question 7: What barriers do you encounter while dealing with nursing
students in the clinical setting?
The unit staff nurses described barriers associated with not knowing what level of
student they were working with, and difficulty in the constant flow of students rotating
through their floors. All of the faculty, in contrast, described barriers in logistically
having students assigned to a variety of clinical units. The majority of faculty discussed
having students assigned to nurses who did not want to participate in precepting nursing
students as evidenced in the following quotations:
We're (students) in different geographical locations (during the clinical day)
I've had one clinical experience, or one clinical institution, where all my
students were on the same floor. There was so much learning that happened
every single clinical day. (Faculty A)
Some facilities I've been in have had situations where the nurse refused to
take a student. I've reported it to management. I've reported it to the school.
Pretty much the same answer I get is we're sorry but that nurse just doesn't
take students. As far as what I can see, it's not a requirement for nurses to take
students. I guess it's highly encouraged but some of the floors we've been on,
it's not been a requirement. (Faculty D)
I'm constantly rounding. In fact, I checked my phone one day to see how
much I had walked through the hospital that day and it was over 5 miles that I
had walked. My students are on five different areas of the hospital. You just
can't get to every student every time. Sometimes when you do get to the
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student, they could be with a nurse, with a patient, or just honestly in an
unknown location. (Faculty C)
The big challenge sometimes is you are on Floor 11 and then there are 2 other
students who need your assistance on Floors 2 or 5. It's just the constant
rounding that makes it hard and challenging at times (to facilitate learning)
As much as possible, I try to meet with the students and discuss patient
priorities.
(Faculty B)
The unit staff nurses described how there was inconsistency in school and faculty
expectations of students. Some schools allowed students to do certain procedures but
others would only let the student perform skills if the clinical instructor was present. They
described different clinical expectations as creating confusion for staff nurses and how
these varied expectations negatively impacted student learning on the clinical unit. It is
sometimes not never really knowing (the student’s clinical objectives) and just what that
particular student can do and that's kind of a common thing. They'll hand me a typed,
written or document that will say, "This is what I can do," and to be honest I'm so busy I
don't always have time to read it... I'll just have them verbally let me know what they can
do, but I wish there was a better way of knowing. If we had that same student week after
week or the same group so we knew but that's the thing that slows us down, really
knowing just what they can do and what they can't. (Unit Staff Nurse E)
The responses to this question revealed there are many different schools with a
variety of educational levels rotating through the medical-surgical clinical units every
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week. Compounding this problem is the student clinical blocks are scheduled every eight
hours. Furthermore, the student clinical shifts occur during the unit staff nurses scheduled
twelve-hour shift. The large influx of students from a variety of nursing schools makes
identifying learning objectives and goals almost impossible for the staff nurses as they are
already very busy with caseloads.
Research Sub Question 5: How do faculty and unit staff nurses describe critical
thinking and clinical reasoning and why are these skills important for students in the
clinical setting?
Interview Question 14: How would you describe clinical reasoning? There
was distinct difference in how faculty described clinical reasoning compared to the unit
staff nurse. The faculty related clinical reasoning to identifying how to assess and make
decisions about the client’s care. In contrast, the unit staff nurses identified clinical
reasoning in association with teaching students as looking at the whole patient or made
no distinction between critical thinking and clinical reasoning skills.
“If they (student) cannot show signs of clinical reasoning …they’re just completing tasks.
We don't want nurses that can only complete tasks” (Faculty B). “Clinical reasoning is
looking at a patient holistically. Prioritizing the patient's illness, what they're there for (in
the hospital)” (Unit Staff Nurse A). “I think clinical reasoning is being able to evaluate
your clients and determine the needs of the clients based on the information that you have
and then expected to know potential complications” (Faculty D).
To be honest, sadly I know on this floor so often we're so task oriented that we
really don't really get to spend the kind of time that I'd like to do in those areas
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(teach clinical reasoning) unless I'm seeing a problem then I will show them and
teach them, "Look this is what we're looking for. This is how we're trying to help
this patient," but sadly we are just trying to do the task at hand, trying to get our
meds passed on a timely matter.
“Clinical reasoning? (It is) Critical thinking in the nurse setting.”
Interview Question 15: How would you describe critical thinking? In your own
words, describe the difference between critical thinking and clinical reasoning.
Faculty were able to define critical thinking and clinical reasoning in regards to student
performance in the clinical setting. Furthermore, faculty were able to give clear examples
and illustrations of how they developed these two critical skills. In comparison the unit
staff nurses did not have clearly defined examples of critical thinking and clinical
reasoning in relationship to teaching or assessing students in the clinical setting. Critical
thinking to me is advanced multi-tasking. It's being able to understand how the body
system works as related to the disease process. Clinical reasoning is same thing, but
maybe a little bit more advanced. It's, again, going back to looking at the patient
holistically. You can even go beyond that. Not just looking at one patient, but looking at
your group of patients that you've seen. (Faculty A)
“Critical thinking to me is advanced multi-tasking” (Unit Staff Nurse B).
Table 2
Themes
Themes Codes: Key words in context
Lack of consistency 1. Scheduled hospitals
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2. Scheduled clinical units
3. Definition of critical thinking
4. Definition of clinical reasoning
5. School expectations
6. Faculty expectations
Faculty and staff clinical expectations of
students
1.
2.
Professionalism Communication
3. Student engagement
4. Responsibility
Barriers to clinical education 1. Lack of training
2. Students frequently changing units
3. Short amount of time on units
4. Having students on a variety of
clinical floors.
5. Refusal of assigned student
6. Different nursing programs
7.
No consistency in expectations:
faculty and schools
8. Too many students in a clinical
group
9. New graduate orientees taking
clinical preceptors
Faculty and staff differences in educational
definitions
1.
2.
Critical thinking
Clinical reasoning
Faculty and staff comfort level with students 1. Very comfortable
Resources for clinical education 1. Dedicated educational unit
2. Training
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3. Tool
4. Incentives
Theme 1: Lack of Consistency
Faculty. Faculty expressed frustration in the inconsistency of what hospitals
students were scheduled to report to for clinical rotations each semester. The faculty
described being rotated to facilities based upon availability of clinical slots. If faculty
were scheduled at the same hospitals, there were routine inconsistencies in the location of
assigned clinical units from semester to semester or clinical rotation to clinical rotation.
This constant shifting of hospitals and clinical units creates difficulty for the faculty
members to develop relationships with the unit staff nurses and for the unit staff nurses to
develop relationships with the nursing students.
There was also a lack of consistency in the definition of critical thinking and
clinical reasoning among faculty and unit staff nurses. The faculty gave rich descriptions
of both definitions as well as applying them to clinical education and facilitating learning
of nursing students. Faculty understood how to use Socratic questioning and how to
connect previous learning to new situations for the nursing student. In contrast, the staff
described isolated incidences of teaching and there was not a focus on higher order level
of thinking. The staff inconsistencies connected to lack of training and lack of time with
students to develop relationships in which higher order level of thinking could be
developed.
Staff. Staff described inconsistencies among nursing schools related to student
clinical expectations, and faculty expectations of the students. There were many
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examples offered that included: (a) one school allowing the student to care for more than
one patient, (b) another school would let the student could help care for all patients while
another school would only let the student care for one patient, (c) one faculty member
might let students perform certain tasks, and (d) other schools would not allow students
to do certain skills. Unit staff nurses shared trying to determine what the goal and student
objectives for each clinical rotation was to be a common occurrence during the clinical
day. Unit staff nurses identified keeping up with student and clinical expectations from an
assortment of nursing programs is frustrating. Unit staff nurses identified that time spent
trying to identify student clinical objectives affects the time needed they need to care for
patients.
Theme 2: Faculty and Staff Clinical Expectations of Students
Faculty. Faculty expectations in the clinical setting focused on professionalism,
which included: (a) arriving prepared, (b) dressed appropriately, and (c) communicating
with clinical staff in a professional manner. The faculty participants put a strong emphasis
on expectations of student preparation and taking responsibility for their educational
experiences in the clinical setting. Faculty further described how students must be
responsible for seeking out learning opportunities while in the clinical setting.
Additionally, they expressed as a whole that students needed to care about patients and
families and be cordial with staff and each other in the clinical setting.
Staff. Staff had the same expectations of students as the faculty. They were
consistent as well with expecting: (a) professionalism, (b) student preparation, and (c)
nursing students be self-motivated. They further shared that it was of very high
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importance that the students be responsible and let the staff know what their goals were
for the clinical day and the clinical semester. There was also an expectation from staff
that students would be a part of patient care on the clinical unit.
Theme 3: Barriers to Clinical Education
Faculty. Faculty unanimously remarked about unit staff nurses being experts in
their clinical disciplines but lacked training in facilitating the development of critical
thinking and clinical reasoning of nursing students. All faculty gave an example of how
students in the clinical setting were shifted not only from unit to unit, but were moved
from facility to facility between adult medical-surgical clinical rotations sites. Faculty
remarked how this created an environment not conducive to teaching students clinical
reasoning skills as it hinders the student from reaching a comfort level with the nurses on
a single unit clinical.
Another significant barrier faculty noted was the logistics of having students on
too many clinical units within the facility. The logistical problem creates an environment
where the faculty member is constantly on the move trying to meet with sometimes 10 to
11 students on five different floors in the hospital. The faculty members find there are
several students they just cannot meet with more than once or twice in a clinical day. Not
being able to meet with the students leaves the burden of facilitating the learning process
to the unit staff nurse. Faculty added another obstacle happens when they are in the same
hospital, but not assigned the same clinical unit from one semester to another semester.
All faculty shared frustration in having nursing students assigned to staff nurses
prior to the start of the clinical day who would refuse to precept a student the day of
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clinical, or just ignore or be rude to the student. This situation leads to frustration on the
part of faculty and the student. It takes additional time to contact the charge nurse, get the
student reassigned, and delays the start of critically needed clinical hours for the student.
The faculty furthermore described situations where the unit nurses are assigned new
graduates to precept and this limits the availability of unit nurses able to take a student. It
creates a situation where the faculty member must reassign the student to another nurse
altogether, or reassign the student to another floor. It takes time out of the clinical day and
disrupts the student’s ability to participate in patient care during the morning. This causes
the student to miss report, and early rounds with the unit staff nurse.
Staff. When asked about the need for further training to precept students in the
clinical setting, all but one staff nurse agreed that some form of professional development
is needed to better facilitate student learning in the clinical setting. Staff also noted that a
barrier to creating a better learning environment was the constant influx of students from
different nursing programs. This creates an environment where the nurse is: (a) always
trying to discern the level of student she is precepting, and (b) what the student is allowed
to do and not do in the clinical setting. Further complicating this situation is faculty
rotating students to a variety of clinical units during the semester. Staff nurses remarked
that there is no consistency among nursing programs in regards to student expectations.
Furthermore, there is the issue of trying to contact instructors for permission for students
to perform skills, which takes the nurse away from priority care of the patient. Over half
of the staff remarked that patient care was a priority over teaching students in the clinical
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setting. These barriers make it difficult for the staff nurse to meet the learning needs of
the student.
Theme 4: Faculty and Staff Differences in Educational Definitions
Faculty. Faculty expressed expertise when discussing the assessment of students
in the clinical setting. Faculty defined how critical thinking and clinical reasoning
affected the learning experience of students. They further gave rich descriptions and
examples of how they facilitated the development of critical thinking and clinical
reasoning skills during clinical interactions. They described how they connected didactic
information to the clinical setting. All faculty had a minimum of a master’s degree and
over half of the faculty working with students in the clinical setting were pursuing
doctoral degrees.
Staff. The unit staff nurses frequently described skills when referring to assessing
critical thinking or clinical reasoning skills of students. A few unit staff nurses who
described clinical examples of helping students to think and reason through clinical
scenarios. The unit staff nurse described a variety of reasons, which could have a
negative impact on students’ learning in the clinical setting. They included: (a) lack of
student engagement, (b) lack of knowing clinical expectations, and (c) lack of training to
facilitate the development of critical thinking and clinical reasoning skills. All of the staff
had a minimum of a bachelor’s degree and a few held higher degrees outside of nursing.
Only two of the nurses had participated in training courses to precept students and the
training was not within the last five years. All other unit staff nurses had no training
teaching and precepting nursing students in the clinical setting.
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Theme 5: Faculty and Staff Comfort Level With Students
Both faculty and staff expressed being comfortable with students in the clinical
setting. The faculty referred to this comfort level in association with teaching and
assessing the student in the clinical setting. The unit staff nurses stated they were
comfortable with having students in the clinical units but listed barriers to facilitating
student learning.
Theme 6: Resources for Clinical Education
Faculty. Faculty unanimously agreed more training is needed for staff to better
prepare them to precept medical-surgical students in the clinical setting. The faculty
agreed that an assessment tool to assess critical thinking and clinical reasoning of
students in the clinical setting would help keep faculty and the unit staff nurse focused on
the same learning objectives for students. The faculty commented numerous times that
having students in one clinical unit would create an environment conducive to learning.
Faculty spoke about needing the support and input from hospital administrators,
curriculum committees, and the unit staff nurses to make such an endeavor a success.
Staff. All but one unit staff nurse agreed that there was a need for formal training
in precepting students in the clinical setting. The unit staff nurses shared beliefs that
having students for more than one day or more than one clinical rotation would facilitate
better student outcomes. The staff spoke about not having clear learning objectives for
students and how training could better help them make the student clinical rotation more
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successful. Staff did feel supported by faculty and felt like faculty were approachable
whenever there was a concern regarding student performance or participation on the
clinical unit. At least half of the staff discussed an incentive program might be required to
obtain staff buy-in for attending staff training. Lastly, staff shared the importance of
needing students to come prepared to learn and to be active participants in their clinical
rotation.
Discrepant Data
Conflicting data arises when one or two participant viewpoints disagree or give
different perspectives than the majority of other participants (Creswell, 2012). The results
of this case study identified one participant’s viewpoint that was vastly different from
other participants. This perspective came from one of the unit staff nurse. She was a
seasoned nurse with numerous years of experience who did not think additional training
for staff would be beneficial. The perspective was based on the overall opinion that many
of the unit staff nurses on this particular unit had many years of experience and would not
be open to additional training for precepting students. Additionally, when asked about the
development of a tool to assess clinical reasoning of nursing students, she was opposed to
having a tool. The participant expressed this opinion based on the concern that a unit staff
nurse precepting a student for a short time may not: (a) get along with the student, or (b)
have spent enough time with the student to evaluate the students’ performance. This
could result an evaluation of the student that was unfair or biased.
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Evidence of Quality
I was able to eliminate my own biases with careful attention to only using the
transcribed findings with supporting quotations from participants. Bogdan and Biklen
(2007) suggested that the data collected and transcriptions presents a much richer
description of thoughts and perceptions of the participants than any personal biases can
conceive prior to a study. I took field notes and was able to crosscheck these with the
transcribed interviews to verify the accuracy of the findings. Member checks allowed the
participants to review the transcribed interviews and validate the credibility of the data
collected during the interviews (Creswell, 2012). The participants had 3 days to review
the transcribed interviews, and notify me of any needed changes that might misrepresent
their opinions. No returned e-mail from the participants reflected that the transcribed
interviews accurately represented their views and beliefs. Data triangulation was
accomplished with a comparison of faculty and unit staff perspectives and crosschecked
with field notes. Identifying discrepant data is part of the process of developing validity
in a qualitative study (Maxwell, 2012).
Outcomes in Relation to the Study and Project
The purpose of this qualitative case study was to explore the ability to evaluate
students’ critical thinking and clinical reasoning skills in the clinical setting from the
perspective of both the faculty and unit staff nurse. As I interviewed both faculty and
staff, it became apparent that often the nurses are very busy, patient care is a priority for
the staff nurse, and trying to keep up with the assigned patient load is a priority over
teaching students in the clinical setting. Teaching students is a secondary task for unit
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staff nurses, the majority spoke of being overloaded with patient care. When teaching
does occur there is no consistency in how critical thinking and clinical reasoning are
developed or assessed. The majority of the unit staff nurses interviewed for this study had
no training on precepting students and do not take part in the evaluation of nursing
students in the clinical setting.
There was a distinct gap between what faculty and staff nurses define as critical
thinking and clinical reasoning. Faculty gave rich illustrations in how they facilitated and
assessed students’ ability to think critically and how to facilitate clinical reasoning skills.
Staff, in comparison, explained they did not routinely assess medical-surgical students in
the clinical setting. These are significant findings as the nursing student spends the
majority of her time with unit staff nurses during clinical rotations.
Faculty identified difficulties in having too many students as well as students
assigned to multiple locations. Multiple clinical units make the logistics of faculty getting
to spend quality time with the student facilitating the development of critical thinking and
clinical reasoning with Socratic questioning and dialogue very difficult. It is essential for
the faculty member, or the unit nurse, to use Socratic questioning and dialogue as
teaching strategies because this is a fundamental approach in linking theory to practice in
the clinical setting. Debriefing in the clinical setting and the use of Socratic questioning
contributes to the development of higher order thinking skills in nursing education
(Mariani, Cantrell, Meakim, Prieto, & Dreifuerst, 2013).
Based on the results of the data analysis, there is a distinct need for a shift in the
paradigm of how students are assessed in the clinical setting. This new paradigm needs to
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be a dedicated educational unit that creates a learning environment conducive to teaching
critical thinking and clinical reasoning to nursing students. Students spend the majority of
their clinical hours with the unit staff nurses. In the current clinical model, the unit staff
nurses are not prepared to teach and assess students. Faculty are clearly the experts when
it comes to facilitating the development of critical thinking and clinical reasoning skills
of nursing students but are faced with logistical obstacles that make it impossible to
spend enough time with each student. Once a partnership forms between the school of
nursing and the hospital, a 3-day professional development program for unit staff nurses
will be implemented. The dedicated educational unit will foster a better learning
environment for students, build staff skills for facilitating learning in the clinical setting,
and cultivate the development of critical thinking and clinical reasoning skills of nursing
students.
During data analysis, Benner’s novice to expert theory (1982) served as a
theoretical basis for identifying gaps in the clinical education processes. The theory
provided a basis to compare and assess current teaching and assessment activities in the
clinical setting. A gap was identified among faculty and staff in defining critical thinking
and clinical reasoning. The theory aided me in identifying barriers to teaching and
assessing clinical performance. Without defining criteria, there is no consistency in how
critical thinking and clinical reasoning is defined or taught among faculty and staff.
Faculty will work with unit staff nurses to establish criteria for evaluating critical
thinking and clinical reasoning skills of the novice and advanced beginner. Clinical
reasoning entails many activities and steps for the nurse to process information and is
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very difficult to manage without guiding criteria (Rose & Babajanian, 2016). The Tanner
Model of Clinical Reasoning will serve to guide the professional development of the
dedicated educational unit. It will help establish a common language for teaching and
assessing critical thinking and clinical reasoning. A unit dedicated to educational
practices facilitates the development of students progressing from novice to advanced
beginner in clinical reasoning (Rhodes, Meyers, & Underhill, 2012). The data analysis
established the need for this shift in the educational processes of students. This
professional development project to establish a dedicated educational unit founded on
Benner’s (1982) novice to expert theory will have a positive social impact on clinical
education of nursing students.
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Section 3: The Project
Introduction
The primary goal of this qualitative case study was to explore how faculty and
staff assess critical thinking and clinical reasoning skills of nursing students in the
clinical setting. For this study, six faculty and six unit staff nurses who taught students in
the medical-surgical clinical setting were interviewed. Semi structured interviews were
conducted in order to gain an understanding of how both groups were similar and how
they differed in their assessment of critical thinking and clinical reasoning skills of
nursing students. The interview process allowed the participants to describe their
perspectives, voice their concerns, make suggestions on how the student assessment
process can be improved, identified staff training needs, and revealed the need for a new
model of clinical education.
Data analysis from the interviews revealed themes which guided the development
of the project. There were six themes identified: (a) lack of consistency, (b) faculty and
staff clinical expectations of students, (c) barriers to clinical education, (d) faculty and
staff differences in educational definitions, (e) faculty and staff comfort level with
students, and (f) resources for clinical education. From these themes surfaced the
evidence that helped identify a framework the professional development would be based
upon. A 3-day professional development (Appendix A) was established to address the
unit staff nurses’ educational needs and guide the development of a dedicated educational
partnership between the school of nursing and the hospital. Based on the assessment
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needs from the themes, topics were chosen to guide the professional development and are
as follows:
•Benefits of a dedicated educational unit
•Dedicated educational unit concepts
•Creating an educational workplace environment
•Staff development for the role of precepting
•Roles and expectations of participants
Project Goals
The major objective for this project is to create a situation where faculty and unit
staff nurses have a setting where student learning can occur in a supportive atmosphere to
develop critical thinking and clinical reasoning of nursing students. There are three goals
for developing a dedicated educational unit between the school of nursing and the
hospital: (a) to bring awareness to all stakeholders on the benefits of a formed partnership
for an exclusive dedicated educational unit, (b) educate unit staff nurses on becoming
clinician instructors who are able to facilitate critical thinking and clinical reasoning
skills of students in the clinical setting, and (c) develop a culture conducive to learning
and collaboration. The development of a DEU is intended to provide better collaboration
between faculty and unit staff nurses. Collaboration will offer more opportunities for
faculty and unit staff nurses to identify priorities for teaching and assessing students in
the clinical setting.
The proposed project will address the local problem identified during the data
analysis. Strategies that focus on addressing the educational needs of unit staff nurses
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will better prepare them to precept students in the clinical setting, develop critical
thinking and clinical reasoning of nursing students, and ultimately impacting patient
safety. A collaborative project between faculty and unit staff nurses will create an
environment where the student’s learning is a priority to both faculty and the unit staff
nurse. The unit staff nurses will have training which will allow them to become
comfortable and knowledgeable precepting students. The DEU will foster a positive
culture on the clinical unit that embraces helping develop students as well as a staff of
nurses who are confident in their role of clinician instructors.
Rationale
Professional development is a universal and lifelong responsibility of all
healthcare providers. Today’s healthcare is becoming increasingly complex for nurses to
navigate. Being an effective nurse and preceptor in the clinical setting requires nurses to
pursue professional development (Pool, Poell, & ten Cate, 2013). To become an effective
preceptor who can facilitate learning in the clinical setting requires additional training
and an environment which fosters education. A clinical unit staff nurse might be an expert
in the clinical setting, however clinical knowledge does not correlate to being an expert
educator while precepting nursing students (Carlson & Bengtsson, 2015). As the data
analysis from this study has shown, unit staff nurses do not have training in facilitating
the development of critical thinking and clinical reasoning skills of nursing students. The
current clinical model is burdened with barriers to the educational process that include:
(a) students frequently changing clinical units, (b) students being on the unit a short
amount of time, (c) faculty having students on a variety of clinical floors, (d) staff nurses
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refusing an assigned student, (e) different nursing programs competing for clinical
placements, (f) no consistency in expectations from faculty and nursing schools, (g) new
graduate orientees taking up available clinical preceptors, and (h) no consistency between
faculty and staff in the assessment and development of critical thinking and clinical
reasoning of nursing students.
The most appropriate project will be to form a partnership with the school of
nursing and the hospital to create a dedicated educational unit (DEU). By creating a
DEU, the staff nurses will have professional development to teach critical thinking and
clinical reasoning skills, develop skills to perform student assessments, improve
communication with students, learn how to create an environment conducive to learning,
and providing student feedback. This project will ultimately impact the development and
assessment of critical thinking and clinical reasoning skills of students as the clinical unit
and the unit staff nurses will be better prepared to facilitate student learning in the clinical
setting.
Literature Review
The purpose of this qualitative case study was to explore the ability to evaluate
students’ critical thinking and clinical reasoning skills in the clinical setting from the
perspective of both the faculty and unit staff nurse. Literature searches were conducted
using databases, which included: EBSCO, CINAHL, MEDLINE, ERIC, ProQuest
Central, and outside sources which included Google Scholar. The key concepts and topics
which yielded the most results were clinical education and nurses, clinical environment,
positive nurse role models, educating clinical staff nurses, teaching in the clinical setting,
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clinical education, dedicated education units, clinical education, and frameworks for
clinical education. The literature review was organized around the topics, which yielded
the most information relating to data analysis and barriers in the assessment of critical
thinking and clinical reasoning of students in the clinical setting.
The clinical environment where nursing students work side by side with
registered nurses is a difficult and changing environment as identified in the prior
literature review Section 1. Through the data analysis, I was able to identify barriers and
inconsistencies in how nursing students are assessed in the clinical setting. O’Brian et al.
(2014) found that only about a third of unit staff nurses in the clinical setting received
formal training for being student preceptors. Lack of training in educational methods
makes the time students spend in the clinical unit less of a learning experience and often
more observational for the nursing student (Hilli, Melender, Salmu, & Jonsén, 2014).
Professional development can address this gap in knowledge and create an
environment conducive to teaching and assessing critical thinking and clinical reasoning.
Furthermore, there is a need for clinical staff nurses to have professional development in
the area of clinical instruction, methods of assessment, and the theoretical basis for
teaching nursing students in the clinical setting (Seibert, & Bonham, 2016). Professional
development can enrich the interactions between the nursing student and the unit staff
nurse. Training unit staff nurses is an essential part of how students are taught in the
clinical setting, ultimately impacting how nursing students are integrated into hospital
and the culture of the clinical unit (Cotter, & Dienemann, 2016).
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Creating a Positive Culture
Creating an atmosphere that is both well-structured and accepting of students is
another area that can be enhanced by professional development. The hospital
environment creates high levels of stress for unit staff nurses (Danque, Serafica, Lane, &
Hodge, 2014). Nursing students are at risk for experiencing incivility which creates stress
and is detrimental to student learning in the clinical setting (Babenko-Mould &
Laschinger, 2014). Having professional development that addresses incivility helps unit
staff nurses and unit managers to develop an environment that is beneficial for student
learning and able to nurture the development of critical thinking and clinical reasoning
skills (Laschinger, Wong, Cummings, & Grau, 2014).
Establishing the unit environment should originate with administration and unit
staff managers. Twigg and McCullough (2014) identified the creation of nursing units
that were student friendly begin with the support and leadership from unit managers.
Tanner (2006) asserted that nurses base their clinical decisions partly based on the
environment and influence of the culture of the unit. Socialization of nursing students
with a welcoming atmosphere in the clinical unit makes students feel safe to learn and
helps to prepare them for professional practice (Del Prato, 2013).
Educational Needs of Staff
Providing student feedback can be challenging for unit staff nurses. Nursing
students identified the ability to give constructive feedback to be one of the most
identified and sought after characteristics of unit staff nurses functioning as clinical
instruction (Esmaeili, Cheraghi, Salsali, & Ghiyasvandian, 2014). Professional
89
development is needed to educate unit staff nurses on evaluating and providing student
feedback in the clinical setting (Kang, Chiu, Lin, & Chang, 2016). A critical component
to a successful clinical unit where nurses act as preceptors is highly trained unit staff
nurses who can socialize and efficiently teach and assess nursing students (Mann-Salinas,
2014). Professional workshops are ideal for unit staff nurse preceptors to gain valuable
skills to improve collaboration with nursing schools. Nurses who attended professional
workshops for the development of precepting skills found the training highly beneficial in
future interactions with nursing students (Jeffries et al., 2013).
Barriers to Professional Development
A component to professional development involves identifying barriers to
individual participation. Interviewing and talking to staff is one piece of the puzzle to
discovering why unit staff nurses are reluctant to participate in professional development.
Seeking input from unit staff nurses is a technique that can help deconstruct resistance to
professional development (Lee & Daugherty, 2016). Gaining stakeholder buy-in can be
accomplished through presentations of research-based information that supports
professional development and organizational changes (Bressan et al., 2016). Bressan et al.
further identified that bringing awareness to nurses and encouraging collaboration could
have a positive impact on how hospital staff viewed changes.
Conceptual Framework
The Tanner (2006) model of clinical judgment will be used to guide this
professional development project. The model describes the four stages, or levels, in the
development of clinical judgment. These four phases illustrate the major components of
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clinical judgment associated with the patient care setting. The main concepts are noticing,
interpreting, and responding to changes in the patient’s status. These are followed by the
fourth step, the thinking-on-action skills using reflection after responding to the situation
(Lasater, 2011). The four steps form the basis of clinical reasoning in the professional
practice setting. Assessing nursing students’ knowledge at each phase is important for
establishing growth and identifying gaps in knowledge. With these assessments, teaching
strategies can be developed for unit staff nurses, which focus on how to develop and
assess clinical reasoning and critical thinking of nursing students in the clinical setting.
The Tanner model of clinical judgment establishes the background of why clinical
judgment requires critical thinking and clinical reasoning skills and illustrates how
clinical reasoning and critical thinking is a very complex phenomenon (Cappelletti,
Engel, & Prentice, 2014). Noticing is the first concept in Tanner’s model and is a key
foundational concept in the clinical nursing model where pattern recognition begins
(Appel, Wadas, Talley, & Williams, 2013). The patient is in a constant state of change and
has the potential to decline rapidly. Without the nursing process, unit staff nurses are
more likely to miss relevant cues and make appropriate decisions related to patient care
(Kalisch, Tschannen, & Lee, 2012). Assessment is the first concept in the nursing process
and begins with the nurse’s ability to observe signs and symptoms that the patient is
experiencing as well as identifying failure of the patient to exhibit expected clinical
manifestations.
Noticing is a nurse’s ability to make appropriate observations, to recognize actual
and probable patient problems, to intercede, and to prioritize care. To do this effectively,
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the nurse must be competent in her decision-making ability (Tanner, 1987). A nurse’s
ability to utilize noticing effectively, meaning the ability to recognize the smallest signs
and then analyze and interpret the signs, varies with the clinical practice setting. The
background and experience that the nurse has, as well as in what context the nurse is
caring for the patient, play an important role in how the nurse responds to changes in
patient acuity (Dillard et al., 2009). Noticing involves identifying verbal and nonverbal
cues from the patient. This is a fundamental ability that leads to nurses developing
intuition over time, which is a foundation to establishing clinical reasoning skills (Benner
& Tanner, 1987). Experienced nurses who work in the same units over time are more
likely to draw on knowledge that is specific to that unit, and this experience enables the
nurse to be more aware of changes in patient acuity (Victor-Chmil, & Larew, 2013). This
is a skill that nursing students need expert facilitation with in the clinical setting.
Interpreting is the second step in the model and entails deciphering what was
noticed during the first phase. Nursing care is based on how this information is processed
and interpreted (Gerdeman, Lux, & Jacko, 2013). The nurse’s ability to notice a change
in a patient’s medical condition and then determine what actions are most appropriate is
paramount to safe nursing practice (Tanner, 2006). This process is done over and over
again by the nurse every day in the clinical setting and sets the foundation for developing
clinical reasoning skills. Over time the nurse is able to begin to see and recognize
patterns in patients’ behaviors and response to treatment. A novice nurse struggles with
interpreting and relies on experienced nurses and faculty to guide them through the
process (Robert, Tilley, & Petersen, 2014). The nursing students are bound by limited
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experience and rely on textbook examples as they lack clinical reasoning skills (Benner,
2004). The expert nurse can quickly process and interpret numerous sources of
information, including the patient and the environment, and simultaneously make
decisions in regards to patient care (Payne, 2013).
This process results in the third step of the decision making model and it is
referred to as the responding stage. Responding is where the nurse has interpreted the
signs and symptoms from the patient and then makes critical decisions in regards to the
nursing care (Kelly, Forber, Conlon, Roche, & Stasa, 2014). This process can range from
simplistic to very complex decisions. In order to make correct decisions concerning
patient care, the nurse must use comprehensive clinical judgment (Cappelletti et al.,
2014). For nursing students, decision-making at this level requires expert guidance as the
students lack the competency to demonstrate comprehensive clinical judgment. The
Tanner (2006) model of clinical judgment “provides language to describe how nurses
think when they are engaged in complex, undetermined clinical situations that require
judgment” (p. 209).
Reflection is the fourth stage of the Tanner model of clinical judgment. Reflection
in the clinical setting involves the nurse evaluating clinical decisions after they are made
in regards to patient care. The experienced nurse makes links between clinical decisions,
theory, and research during reflection (Nielsen, Stragnell, & Jester, 2007). Reflection is
often used in the clinical setting for evaluating student performance and the faculty
member is usually the catalyst to help bridge the gap between clinical decisions and
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theory. The process of reflection facilitates nurses and nursing students making sense of
practice (Asselin, Schwartz-Barcott, & Osterman, 2013).
The Tanner model of clinical judgment will create a common language to assess
student critical thinking and clinical reasoning by faculty and unit staff nurses. As this
model is comprised of established stages of clinical judgment, it will serve as a common
language that faculty and unit staff nurses should be using as a guide for consistency in
evaluating the nursing student’s ability to use clinical reasoning skills and critical
thinking in the clinical setting.
Making decisions about patient care in the clinical setting is based upon the
development and use of critical thinking and clinical reasoning skills (Mariani, Cantrell,
Meakim, Prieto, & Dreifuerst, 2013). Intuition is a process established on experience in
the clinical setting where the nurse has a feeling that something is not quite right with a
patient and acts on this intuition by initiating the nursing process (Cork, 2014). The
Integrative Model of clinical judgment it a circular process where the nurse or nursing
student cycles through various stages of clinical reasoning (Tanner, 2006). This cycle
ends with the process of reflection and once this step is complete, the process may begin
again. Over time the nurse develops increased competency in critical thinking and
reflection and develops a deeper meaning while cycling through each of the four phases.
The complex critical thinking stages are composed of context, background, and
the relationship of a nurse or nursing student to the issue or patient. Each of the stages
impacts how the nurse or nursing student responds to the four phases of clinical
judgment. The first phase of noticing begins with the nurse’s expectations. At this stage,
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the nurse has an initial understanding of what is happening with the patient and is
beginning to look for changes in the patient’s acuity. Second, the nurse is interpreting the
data. This is supported by the building blocks of recognizing reasoning patterns, analysis
and intuition, and the use of narratives to help interpret the data. The third step occurs
with responding with an action which leads to outcomes. The last stage, reflection on
actions, facilitates a deeper analysis of how the data was interpreted. This stage leads to
critical thinking and clinical reasoning which, over time, sets the stage for how a nurse
views the patient in all aspects of context, background, and relationships. As time and
experience progresses, the nurse becomes more adept at all of the processes. Early
introduction of these concepts will help nursing students develop clinical reasoning skills.
Furthermore, being able to consistently assess these skills will help to define the areas for
needed growth and development (Tanner, 2006)
Tanner’s model of clinical judgment provides a common, and identifiable
language that faculty and unit staff nurses are familiar using in the classroom and daily
practice. Tanner’s model can be used to guide the language and expectations of nursing
students from the beginning stages of critical thinking to advancement into clinical
reasoning (Kim, Kim, Kang, Oh, & Lee, 2016). Kim et al. (2016) further described how
Tanner’s model is useful in setting up the context in which the nursing process can be
broken down for the student and the unit staff to comprehend clinical expectations during
each phase. Rhodes, Meyers, and Underhill (2012) further supported the use of Tanner’s
model of clinical reasoning as a comprehensive model for teaching in the clinical setting
as it uses the expert nurse to guide the learning processes of the novice nursing student. A
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DEU founded on this model can serve to provide the basis of essential learning
experiences, engage the student in a variety of learning scenarios appropriate for each
level, and the model is designed with a strong foundation of critical thinking and clinical
reasoning.
Dedicated Educational Unit
The nursing student experiences a wide variety of clinical placement, sometimes
with little consistency in how they are precepted and taught from clinical unit to clinical
unit (Bisholt, Ohlsson, Engström, Johansson, & Gustafsson, 2014). The clinical setting is
a key component to teaching the nursing student clinical reasoning skills. In a study done
by Benner, Sutphen, and Day (2010), students from multiple teaching institutions were
interviewed and the students identified one key aspect in the ability to learn how to think
like a nurse was lack of immersion into the clinical setting. One of the shortcomings of
clinical experiences is that students rotate facilities and clinical units. This creates tension
for the student and staff members, as both parties do not know each other or the learning
expectations.
Nishioka, Coe, Hanita, and Moscato (2014a) found that traditional units where
students rotate do not allow a chance for students and preceptors to develop a working
relationship (p. 295). This produces a situation where the student is constantly starting
over every time he or she begins a new clinical rotation. Students find that the clinical
experience is often correlated with how well a unit staff nurse does or does not enjoy
having a student nurse assigned to them for the day (Nishioka, Coe, Hanita, & Moscato,
2014b, p. 303b). Due to these circumstances the student never gets comfortable in the
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clinical setting and cannot focus on developing clinical reasoning skills. Clinician
instructors (CI) working in a DEU have the opportunity to promote clinical reasoning
skills during daily interactions where the clinical instructor (CI) can give constructive and
formative feedback (Nishioka, 2014a). Chan (2013) identified that in order to develop
clinical reasoning in the clinical setting students need “autonomy and empowerment” to
work towards good clinical reasoning skills (p. 23).
Nursing programs have an obligation to identify best practices and explore
innovative teaching strategies that promote critical thinking (Burrell, 2014). A key goal
for instructors teaching in the clinical setting is to promote the growth of clinical
reasoning skills of the student (Alfaro-LeFevre, 2015). This is done by personal one on
one dialogue in the clinical setting where the CI and faculty instructor use a variety of
teaching strategies to better develop critical thinking and clinical reasoning skills. The CI
has advanced training in the role of adult learning theories, teaching, assessment
strategies, and handling difficult and challenging students in the clinical setting (Reid,
Hinderer, Jarosinski, Mister, & Seldomridge, 2013).
Teaching in a DEU allows for a personalized educational experience for nursing
students. Clinician instructors working with the same students for multiple clinical
rotations can identify how a student learns in the clinical setting. Some students are
hands-on learners while others may learn better by watching a nursing action multiple
times before trying a skill. Due to the dynamic shifts in today’s healthcare setting, nurse
educators are looking for teaching strategies that can improve critical thinking (Kong,
Qin, Zhou, Mou, & Gao, 2014). Problem-based learning (PBL) taught in the clinical
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setting has the potential to develop critical thinking of nursing students. Learning in the
clinical environment utilizing PBL engages students by self-directed exploration of data
and situations (Martyn, Terwijn, Kek, & Huijser, 2014). Learning in this fashion helps
establish patterns for critical thinking, which are fundamental to the novice nurse. This
style of learning is student-centered learning and is an influential tool in the development
of critical thinking and clinical reasoning (Martyn et al., 2014).
Using DEU and staff nurses to foster PBL in the clinical setting creates a learner
centered environment for nursing students and can be tailored for a diverse student
population. Experiential learning is associated with education in the clinical setting.
Experiential learning is very applicable to any discipline that has a clinical component
because it has the development of knowledge, skills, and behaviors that are important to
learning patient care (de Oliveira, 2015). Working one-on-one in a consistent setting
allows for the CI to identify the nursing students’ style of learning and tailor their
educational experience. Identifying the learning strategy of the nursing student and then
aligning that with a particular style of learning impacts the student’s abilities to think
critically in the clinical setting (Seibert et al., 2016).
Role modeling is an identified form of teaching in the clinical setting as the CI is
constantly modeling clinical reasoning skills. When a student has the opportunity to work
with the same CI, the student is able begin to identify patterns that the unit staff nurse
does routinely, which is clinical reasoning, while making decisions in regards to patient
care throughout the clinical day. A student centered clinical unit that is designed to offer
consistency in keeping students paired with the same unit staff nurse found students
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favored this learning environment over the traditional model of rotating preceptors and
unit staff preceptors (Jefferies et al., 2013).
The DEU will exist between one nursing school of education and one hospital
system with designated units for clinical rotations. The use of expert CIs to teach in the
clinical setting with a dedicated faculty member overseeing the learning environment is
how a DEU is designed to function (Freundl, 2012). With this design teaching and
evaluation strategies implemented by the CI can be tailored to meet the learning goals of
the school and the individual nurses. This project creates an environment where both
faculty and staff will work towards evaluating critical thinking and clinical reasoning
with the same criteria and learning goals.
Project Description
Stakeholders
The stakeholders in this project include the faculty members from the university
as well as the nursing students and future employers, such as representative from a local
hospital. The stakeholders are the primary people from both institutions who contribute
input during planning (Cafferella & Daffron, 2013). The faculty member is responsible
for creating a learning environment conducive to teaching clinical reasoning and to create
a learning environment that fosters the development of clinical reasoning. Stakeholders
are chosen based on breadth of experience and knowledge, as well as having a motivation
and ability to express opinions that can affect a given situation (Addington et al., 2014).
As a stakeholder, the learner brings to the table the responsibility of coming to the clinical
unit prepared to engage in the learning process and to contribute to caring for patients and
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to participate in critical reflection, which is part of the Tanner model of Clinical
Judgement. Finally, the university itself has a vested interest in producing students who
can pass the National Council Licensure Exam (NCLEX) required for nursing students in
order to become a licensed nurse.
Existing Project Support
Faculty. The medical-surgical faculty from the school of nursing are experts in
the assessment and development of critical thinking and clinical reasoning of nursing
students. The faculty will be available to help host the 2 day in-person training sessions
and will serve as preceptors during the second 4 hours of Day 1 training. This will be
scheduled individually during month 1 of training. Faculty will participate in breakout
sessions and help lead discussions during both days of in person training.
Hospital administration. The hospital is a facility which supports research and
professional development. They will offer support to the clinical directors and unit
managers and offer an incentive for the unit staff nurses who commit to being part of the
new DEU. The incentive plan will be designed by the hospital once the concept of the
DEU has been described and introduced to the unit staff nurses. The hospital
administration will agree to provide resources for the professional development such as
space, and computers for the on-line training sessions if the unit staff nurse does not have
access to a computer.
Space. The professional development will be hosted by the hospital education
department. The hospital has a large array of classrooms available as they host
educational events and support group meetings on a daily basis, as well as professional
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development for physicians, and staff in all departments. There are classrooms that can
host up to a hundred participants. There is an array of technology in every classroom for
presentations and enough space to do breakout sessions for the in-person staff training
days. There is also an onsite cafeteria and catering service which will provide a catered
lunch for both days of training.
Potential Barriers
The first source of resistance might come from other faculty members and unit
staff nurses who might not approve of establishing a DEU. The hospital administration
could offer resistance and criticize the fact that there are too many nursing schools within
the metro area to make one floor an exclusive DEU for one school of nursing. Students
might complain they are not gaining enough experience in multiple hospital settings
which could negatively impact potential job placement upon graduation.
An additional obstacle which might prevent the formation of a DEU is hospital
leaderships’ fear of excluding other nursing schools. Faculty may criticize that students
need a greater variety of clinical experiences in an array of clinical units and hospitals.
Another potential barrier could come in the form of unit staff nurses not wanting to
commit to taking a front line role in educating students in the clinical setting.
Solutions
There are a variety of strategies to address each of these obstacles. In the process
of making changes in the clinical setting there should be professional development to
help transition the unit staff nurses. Professional development that can address faculty
attitudes and beliefs is an integral part of facilitating a change that involves technology
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(Ertmer, Ottenbreit-Leftwich, Sadik, Sendurur, & Sendurur, 2012). Assuring stakeholder
buy in before establishing a DEU will assure there is limited resistance from faculty, and
hospital representation. The process of buy in from faculty and unit staff nurses could
include brainstorming and educational sessions on the benefits of establishing a DEU.
Establishing dialogue with the hospital administration could help identify clinical units
outside of the DEUs which may be used by other nursing schools. This process would
help eliminate bias and allow the hospital to still serve the large community of schools of
nursing. Finally, having meetings with the students and listening to concerns allows for
faculty to present students with evidence-based practice to support participation in a
DEU. The same concept also applies to involving the hospital in early planning and
development meetings. The first step is to obtain buy-in from the important constituents
by strategically selling the concept to key members of leadership across an institution
(Gardner et al., 2015).
Faculty rebuttal about students exclusively attending clinical rotations within one
hospital’s DEU could be addressed by referring faculty to the National League of
Nursing’s call for the transformation for teaching nursing students in the clinical setting.
By doing this, it clearly reiterates the importance of designing new clinical experiences
which will provide a richer learning environment for students. The greatest barrier is
perhaps unit staff nurse’s resistance to picking up what is perceived as an additional
assignment to nursing duties in the unit. Gaining buy-in from the unit staff nurse must
include dialogue and presentations on how nursing students can positively affect the
clinical unit, and improve patient care
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Implementation
In order to implement and establish the DEU, I will first meet with stakeholders to
present my research findings. Once all stake holders have agreed to developing a DEU, I
will then identify and implement a project timeline. Meetings will be held over the course
of several weeks with faculty from the school of nursing, hospital administrators, as well
as the hospital education department. Once all stakeholders have agreed on proceeding to
develop the DEU partnership I will work with the hospital education department to
coordinate meetings with unit directors and floor managers. This meeting will help me
identify the total number of unit staff nurses to be trained. Next, I will work with the floor
managers to establish the dates for training and the most efficient way to incorporate
nurses from every shift.
As training will involve multiple shifts, I will offer a 4-hour online module and
post-test for the first month. The nursing staff will be given 30 days to complete the
online module. The education department will review, grade, and track completion of the
online module. Additionally, the unit staff nurse will be required to shadow a
medicalsurgical faculty member for four additional hours and journal about this
experience. I will review journal entries which will be submitted online. In the second
month, I will then offer the second day of training, an eight-hour class that nurses will be
required to attend in person. There will be two classes offered each week for 2 weeks
with a Saturday option for training. In the third month, I will have the final professional
development day. This will be offered in the same format as the second class. After all
unit staff nurses have completed training, I will spend the rest of the clinical semester
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working with faculty, unit directors, and managers to map out project implementation the
following semester. Once this is complete the DEU will launch the following semester.
Roles and Responsibilities
Collaboration between staff nurses, administrators, and faculty members will be
the key to a successful educational program. All entities will ensure that the program
aligns with the hospital mission and the nursing schools mission.
Faculty Members
The faculty members will contribute input to the development of the DEU, and
assist with staff training and implementation, budget considerations, and training staff.
The faculty members bring over 40 years of nursing educational experience. Specifically,
they bring teaching and designing learning experiences and student assessment to the
professional development project. The faculty members will give direction and input for
the educational materials used in training the CIs in their new roles. Faculty members
will also help with the in-person training of unit staff nurses and will precept them during
training. Once the project is implemented in the clinical setting, faculty members will
ensure that the student is receiving feedback from the CI. They will be available to the CI
to address any questions or concerns in regards to student clinical performance and
evaluation during clinical rotations. The faculty member will also be responsible for
working with the hospital education department to develop future CI training.
Administrators
Hospital administrators will choose the unit to be developed into a DEU, supply
conference rooms for training, and provide an incentive for CI to participate in the DEU.
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The administrators have the overall hospital management skills to support the program
and unit staff nurses, as well as the assets to support the instructor. The administrators
will be on-site during training programs, will assure the CIs are supported during the
training process, and make certain the faculty instructor has the facility resources for
training: conference rooms, blackboards, computers, and any other electronic resources.
Administrators will be available during the implementation phase. Administrators will
monitor the transfer of learning and will have the ability in the post-program analysis to
identify any perceived gaps in the transfer of learning. They will enforce any additional
training the CI must attend if there is an identified lack of transfer of learning during
implementation.
Instructor
The instructor develops the final training material and schedules training sessions
with the hospital while organizing resources within the hospital system. Additionally, she
will run training sessions for all CIs and oversee additional faculty who participate in the
professional development program. The instructor will be responsible for facilitating
communication between the CI and faculty members in charge of student clinical
rotations implementation of the online course, and overseeing the in-person training
sessions. The faculty instructor will be available during clinical rotations to support staff
and unit managers and directors.
The instructor unites the whole program, ensuring all participants are supported
and have all available resources. She is responsible for the development of the DEU,
continued collaboration with the hospital education department for continued CI
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development, selecting student participants for the first semester of implementation, and
collecting feedback from the CI, the unit directors, and floor managers. The instructor
will be available to address any concern from stakeholders. She will supply all training
material including didactic materials, hard copies, and flash drives. Additionally, she will
be responsible for the transfer of knowledge by delivering content to the CIs in a variety
of formats including the online professional development with a power point,
roleplaying, and facilitating faculty led group work during the in-person training sessions.
Clinician Instructors
In their new role as a CI, unit staff nurses will contribute to the development of
the DEU, be responsible for attending training sessions to learn about student assessment
and the role of a clinical educator, and precept students during clinical rotations. Unit
staff nurses are proficient in clinical nursing and bring knowledge of patient management,
clinical reasoning skills, medical knowledge, and specialized clinical expertise to the
program. The new CI will be responsible for filling out evaluation forms, turning in
evaluation forms to the instructor provide feedback to the nursing student regarding
clinical performance, and communicate student performance to the assigned faculty
member(s). The CI will take responsibility for transfer of learning in regards to becoming
a clinical educator on a DEU. Post program analysis will allow the CI to identify any
gaps in transfer of learning.
Project Evaluation
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Summative Evaluation
The establishment of a monitoring process assures that the professional
development goals and objectives are being met. Monitoring is important for
troubleshooting and solving issues to assure the professional development is a success.
Part of the solution to identifying and solving issues is “being willing to be flexible in
where, how, and when you provide the instruction” (Caffarella & Daffron, 2013, p. 190).
It is crucial to the stakeholders to receive feedback during the assessment process to gain
insight for planning future professional development. A paper copy of a Likert survey and
open-ended questions will be used to evaluate the professional development program.
The professional development evaluation will be used to judge the success of the training,
gather information in regards to instructor performance, and capture the participant’s
perspective of the learning process. Following the first semester after implementation of
the DEU, data will be gathered from hospital administrators and faculty group interviews.
The data will be used for developing future professional development programs for the
CI’s.
Formative
Monitoring during the implementation of the DEU will allow for quickly
identifying problems and resolving issues as they occur to determine if the participants
are transferring knowledge to daily practice. Maintaining open communication between
all participants during DEU implementation is critical for a cohesive working
environment that allows for adaptation and change. Specifically, during implementation,
the instructor will facilitate communicate between unit staff nurses and faculty members
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as well as the hospital administrators. The instructor will be responsible for monitoring
learning outcomes and transfer of learning, collecting assessment data, and keeping track
of issues that arise during program implementation. Moreover, the instructor will meet
with hospital administrators and faculty each semester to discuss issues associated with
the DEU.
Formative monitoring will continue over the course of the following semester
during implementation to ensure the transfer of learning. Initial data will be analyzed and
presented by the instructor to faculty and hospital administrators. Meetings will be held
monthly between stakeholders to discuss program modifications and the instructor will be
the point of contact and serve as the facilitator between all stakeholders.
Overall Goals and Evaluation of Goals
The findings from this research study revealed a gap in how students are assessed
and taught by faculty and unit staff nurses in the clinical setting. A literature reviewed
informed that a partnership to form a DEU would address the barriers identified during
data analysis. In order to form a DEU, unit staff nurses need to attend a 3-day
professional development course. The first goal of evaluation is to determine how the
participants perceived the 3-day professional development course. Specifically, how well
the training addressed learning preferences and if the training prepared them to be
clinician instructors in the DEU needs to be known. The second evaluation of goals will
be done post DEU implementation and will assess hospital administrations’ perspectives
on how the DEU has impacted the hospital, the staff RNs, and the new graduates who are
hired by this organization.
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Stakeholders
The stakeholders are the primary people from both institutions who contribute
input during planning and who have a stake in the program (Cafferella & Daffron, 2013).
The faculty and hospital staff members are responsible for creating a learning
environment conducive to teaching clinical reasoning that fosters the development of
clinical reasoning. The stakeholders involved in this professional development project are
the school of nursing, faculty, hospital administration, unit managers, unit directors, CI’s,
and students. Both institutions strive to develop nurses who think critically and excel at
clinical reasoning when caring for patients. The school of nursing has the focus of
educating new nurses, and the hospital, as a major entity in the community, has the
responsibility to offer the highest level of safe patient care.
Implications
The proposed program joins the expertise of both faculty and unit staff nurses into
a partnership, which can enhance the educational process of nursing students in the
clinical setting. This program will educate unit staff nurses on developing and assessing
the critical thinking and clinical reasoning ability of the nursing student. The proposed
professional development will create an exceptional clinical unit with a high level of
focus on education nursing students in the clinical setting. Improved teaching and
assessment of clinical reasoning skills in a DEU will serve to better prepare nursing
students to enter practice with an increased level of safe patient practioners. An
established relationship between students and the dedicated educational unit will allow
for the hospital to recruit and retain nursing students who are a good fit for the institution.
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Conclusion
The results of this study indicated that in order to provide more comprehensive
and unified assessment and teaching of clinical reasoning skills of nursing students a
partnership needs to be formed between the university and the hospital. From this
partnership, there would be the formation of a DEU where students would spend their
medical surgical rotations for two semesters. The formal training the unit staff nurses will
receive from the professional development program will allow the new CIs to better
facilitate and evaluate critical thinking and clinical reasoning skills of students. The
formation of the DEU it will take the guesswork out of what level of student the nurse is
working with and will allow nurses to become very familiar with student learning
objectives. Being in the same clinical unit will foster students to develop relationships
with the CIs. By having these established relationships, it will facilitate the students to
focus more on learning critical thinking and clinical reasoning skills than continually
trying to adjust to a new clinical setting. Continued monitoring of the DEU, once it is
implemented, will allow for stakeholders to identify and work through any issues and
provide additional training for the clinical unit.
Section 4: Reflections and Conclusions
Introduction
There is a national call for nursing education to advance educational paradigms to
meet the needs of a diverse healthcare environment and for these changes to be
established thru research by doctoral prepared faculty (Schnetter et al., 2014). Preparing
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nursing students who are better equipped to step into this diverse healthcare environment
is a priority of nursing programs at the local, state, and national levels. Identifying ways
to better prepare nurses to think critically and be better prepared was my goal when
beginning this journey. In Section 4, I identify project strengths and limitations as well as
make suggestions for alternative approaches to the local problem identified in this case
study. This section includes a description of my personal journey of scholarship,
leadership, and change. I also reflect on myself as a practioner, scholar, and as a project
developer. I identified the potential social change this study can influence, and made
recommendations for further research projects.
Project Strengths
The strength of this project is it provides a solution to a local problem of
inconsistencies between faculty and unit staff nurses in the evaluation of critical thinking
and clinical reasoning of nursing students. There is a call for nursing educators to
research and to develop solutions to educational challenges within nursing education
(Broome, Ironside, & McNelis, 2012). Through a qualitative case study design, nurse and
faculty perceptions were explored and a variety of reasons were identified contributing to
inconsistencies in how critical thinking and clinical reasoning skills were assessed and
taught in the clinical setting. After carefully analyzing the data, a solution was developed
and a professional development program was organized to address the data findings,
which were leading to inconsistencies in student assessments. Current researchers
addressed the need for consistency in how nursing students are taught ad evaluated in the
clinical setting (Papathanasiou, Tsaras, & Sarafis, 2014).
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The strength of this project came out of the formation of a partnership to form a
DEU and the resulting professional development of unit staff nurses to create a consistent
environment for students to develop critical thinking and clinical reasoning skills. The
formed partnerships between schools of nursing and clinical units encourages the unit
staff nurses to become more involved in the education of nursing students who they
precept on their clinical units (Beal, 2012). It further gives students a chance to become
comfortable in their learning environment and focus on learning in the clinical setting.
The DEU creates an environment where student centered learning, as well as patient care,
is a primary focus. Another strength of this project is the support from all stakeholders on
both sides. Buy-in from the stakeholders creates a stronger environment for project
success as backing is gained from many participants (Gold, McLaughlin, Berenson, &
Bovbjerg, 2012).
Addressing Limitations
The limitations from this study in regards to the proposed project comes in the
form of limiting the use of clinical units for only one school of nursing. As there are
numerous nursing schools in the metro and surrounding communities, it creates limited
space for students to do clinical rotations. Although buy-in from stakeholders will be
favorable for the duration of a pilot semester, it may be difficult to maintain an exclusive
DEU for one school of nursing. Another limitation concerns how well unit staff nurses
embrace becoming clinician instructors. In order to become comfortable and efficient in
this new position it will take more than one semester to develop solid teaching and
assessment skills and combine this role into the role of a unit staff nurse.
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The unit staff nurse may not be open to participating in the professional
development program or desire to have additional responsibility for teaching and
assessing students in the clinical setting. Students have varied personalities and may or
may not fit into the environment of the assigned clinical unit. If there is dissention among
the students and clinical staff it could limit the success of the newly formed DEU.
Alternative Approaches
There are a few alternative methods that could have been considered for this
project. One such method would involve keeping the professional development to an
online format. Moreover, the professional development would not involve the
development of a DEU. With this format nurses would not have an opportunity to
collaborate and apply what they had learned in the online environment. Pool et al. (2013)
identified other forms of nurses undertaking professional development via reading
professional journals, and learning from colleagues or formal learning activities (p. 41).
Pool et al. further described that nurses in his study were surveyed, and they preferred a
variety of learning methods dependent upon experience and influence from coworkers.
Knowles (as cited in Merriam, Caffarella, & Baumgartner, 2007) described the adult as
being self-directed and able to contribute to decisions in regards to his or her learning
needs and experiences as well as the evaluation of those experiences. By using a variety
of learning strategies, I am meeting the needs of the adult learner. This project involves
an online module, and in-person training that includes group work as well as role-playing
among the unit staff nurses and faculty.
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Scholarship
Throughout the journey of my EdD program I have developed the needed skills to
implement the scholarship of research. My scholarship skills are just forming at this stage
and will take years to refine. I have learned a tremendous amount during this rigorous
process and fill confident that I can move forward in nursing education and replicate
these steps and produce and implement a project based upon what I have learned from
this study.
An important part of my scholarship journey was the development of research and
discovery. The process of identifying a local problem and writing it up in a scholarly
manner, and finding supporting literature on a broad scale was a very difficult process
that took considerable refining. Scholarship in nursing education needs to identify and
develop educational strategies to address the call for educational reform (Nardi &
Gyurko, 2013). Developing a literature review to round out and support the different
pieces of the local problem and problem on a larger scale was daunting. However, being
able to finally narrow down and define the contributing factors related to the problem
was a challenging and rewarding experience. The practice of analyzing the data and
discerning the broad themes to the most important findings was also a difficult task but
one which I am able to walk away from and identify as a personal strength.
Project Development
The professional development and project design was a part of the scholarship
journey that I felt confident in developing. I chose to address the problem with
professional development as it directly addresses the identified gap in how to teach
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nursing students and assesses critical thinking and clinical reasoning in the clinical
setting. This professional development involved creating a partnership to serve the
clinical education of the nursing student. The training addresses the research findings by
equipping the unit staff nurses to be frontline leaders in the educational process of
teaching critical thinking and clinical reasoning skills. It creates a centralized location,
which addresses a multitude of barriers identified during data analysis.
The online portion of training allows the unit staff nurses to gain an understanding
of the language associated with teaching students in the clinical setting. As this is an
online platform, it allows nurses to access and engage in the training at their own place
and at a convenient time. Online learning offers the student an instructor moderated
experience with the ability of individual and group learning (O'Neil, Rietschel, & Fisher,
2013). The in-person workshop offers training from faculty members who are expert
clinical educators and who are passionate about developing clinician instructors (CI) that
influence the learning of nursing students in the clinical setting. The nurses are inspired
and learn role-playing techniques that are applicable to their new role in a DEU. The
roleplaying workshop also features sessions which allow the unit staff nurses to interact
with faculty and ask questions. Role-playing offers participants a variety of opportunities
to act out potential scenarios and provide solutions before encountering real-life
situations (Lee, Cawthon, & Dawson, 2013). Providing role-playing and a question and
answer time permits the unit staff nurses to work through their concerns prior to
implementation.
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The active learning strategy engages the adult learners and keeps them engaged in
the learning process. This allows the adult learners to bring their life experiences to the
learning process. Knowles (as cited by Merriam et al., 2007) described the adult as being
self-directed and able to contribute to decisions in regards to his or her learning needs and
experiences as well as the evaluation of those experiences.
By working on each phase of the project, it allowed me to think through the
phases of role developer and participant. The process of researching a problem and seeing
it through with a project that offers a very tangible solution is empowering. From this
experience, I will look at all of my future research projects with a fresh perspective and
continually look for ways to implement a solution based on the findings from data
analysis.
Leadership and Change
My research focused on critical thinking and clinical reasoning, which are integral
to nursing education. This experience has allowed me to impact a social change on a
local level. I have a fresh perspective about how educational changes need to begin on a
local level, influence a state transformation, and then broadened to a national level.
Although I do not carry a high rank in my educational setting, I have seen the potential of
how I can influence change. I can do this through research and develop a project that can
accurately address the educational change nursing leaders have been calling for on a
national level. Foli, Braswell, Kirkpatrick, and Lim (2014) found that leading and
developing a project while in school developed leadership skills that can carry over into
practice. The development of the project has shown me that I am a leader and that I am
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capable of initiating educational changes in nursing education at a local and community
level.
Analysis of Self as a Scholar
My doctoral journey began with a friend referring me to Walden University’s EdD
program during a summer clinical we were coteaching. With an e-mail confirmation of
my acceptance to the program, my journey began 3 years ago. As a first generation
college student, I was proud to have completed an MSN in Nursing Education. I was able
to attend my master’s program in person and had a small support group that encouraged
my growth and development. However, I never considered my ability to achieve a
doctorate, nor I did not think of myself as a scholar.
I was terrified of an online program. I was quickly immersed into a professional
environment where scholarship was taught from day one. Each paper and discussion post
helped me develop into the scholar I am today. Furthermore, this journey has equipped
me to continue to grow and develop as an educator. It has taught me that a person must
never be finished learning and must always have self-analysis of scholarship as a teacher
and a researcher. The immersion into this study has made me aware of numerous other
issues facing nursing education in and out of the clinical setting, which we must begin to
address as nurse educators. When I complete this study I have plans in place to enter
immediately into another study with one of my doctoral prepared friends and mentors.
Analysis of Self as Practitioner
The educational field of nursing is finally beginning to change. As a practitioner,
it is my job to continually evaluate practice and to develop as a professional. This means
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that I actively engage in the educational process of my students. Being a practitioner
means looking for ways to continue to improve practice and continuing to add knowledge
to the field of education (Creswell, 2012). Evaluating at myself as a practitioner in
relation to this project, I feel like I have made a significant social impact in nursing
education at my local level. When considering project development, the practitioner must
look at a multitude of stages to be successful. Caffarella and Daffron (2013) identified
knowledge of the projects context, developing a support base, establishing goals and
objectives, and developing the format and an appropriate schedule and timeline. When I
evaluate myself based upon these criteria I feel like I met these steps of project
development. In establishing a support base, I used all the stakeholders’ input and buy-in
for developing the partnership and the professional development of the unit staff nurses. I
was able to clearly identify goals and objectives as well as work with administrators, unit
directors, and managers to establish a timeline for professional development and
implementation of the DEU.
Analysis of Self as a Project Developer
As a project developer, I have been inspired to create a project that can serve the
local community and impact how critical thinking and clinical reasoning are taught in the
clinical setting. I have participated in project development in the past, but this has been a
new experience creating a project from start to finish. Having previous learning
experiences with projects was beneficial to my ability to look at this project from a
variety of stakeholder viewpoints. I was able to draw on my experiences as a clinical
nurse, faculty member, and unit manager. The results of the data analysis gave guidance
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to the final project and fulfilled not only a way for student nurses to be assessed by
faculty and unit staff nurses, but will also serve the school of nursing and hospital in a
variety of ways. This gives me a sense of accomplishment that the project can have a
greater impact on nursing education other than just providing a way to cohesively assess
student critical thinking and clinical reasoning skills. This EdD journey has opened a
whole new world of growth and opportunities.
Reflections
Implications, Applications, and Directions for Future Research
When completing a research project, it is essential to look at future research
opportunities that can originate from the study. While this project provides a solution for
providing a more cohesive way for faculty and staff to assess and teach critical thinking
and clinical reasoning skills, there remains other significant pieces to clinical education if
explored could bring a significant contribution to nursing. The impact of a DEU on
patient satisfaction could be explored as well as what effect the new role as a CI has on
the unit staff nurses. Future research in nursing education needs to include the use of a
DEU to impact patient care (Glynn, McVey, Wendt, & Russell, 2016). Additional
research could focus on nurse workloads, and retention of students as future employees of
the DEU where they did clinical rotations. On a local and national level, nurse educators
must work together to research and develop an instrument to measure critical thinking
and clinical reasoning specific to nursing as these skills are fundamental to becoming safe
nurse practioners.
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Social Impact
The Nursing and Care Quality Forum (NCQF, 2012) called for keeping quality
and safety at the forefront in nursing education and patient care. This project can make
significant contributions to affect positive social change. This project creates professional
partnerships that will have a focus on developing the critical thinking and clinical
reasoning skills of nursing students. The partnership will also put the learning needs of
the nursing student as a priority for both academic and clinical institutions. The project
has the potential to impact student learning outcomes, and develop nursing students who
are better prepared to enter the workplace. It develops an environment in the clinical
setting where student learning is a priority to all stakeholders. The DEU can further make
a positive impact on patient satisfaction by providing another set of hands and ears to pay
close attention to patient acuity and care for patients.
The project can help the hospital recruit and retain nurses for the clinical units.
The new graduates who enter practice from this partnership will require less precepting
over the long run as they have had extensive exposure to the unit. Ultimately, establishing
evidence based practice is important to nursing education in order to make informed
decisions about how students are taught and perform in the clinical setting (Grove, Burns,
& Gray, 2014).
Conclusions
Nursing education is at a critical junction in the 21st century. Nurse educators
must continually strive to evaluate self-practice and be involved in research to better
determine what practices need to be further developed and what educational practices
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must be changed. Critical thinking and clinical reasoning skills are two vital skills to
nursing practice. The establishment of this project met the needs evidenced by the
research and data analysis by providing training for unit staff nurses in the teaching and
assessment of critical thinking and clinical reasoning skills. The qualitative design
allowed me to analyze data which provided rich perspectives representing what faculty
and unit staff nurses perceived as the gap in the assessment of nursing students. As a
novice researcher, I was able to bring the stakeholders information that served as a basis
for a partnership that provides further professional development of nurses and establishes
a clinical unit dedicated to preparing nursing students for future practice.
