Integration of innovative clinical reasoning pedagogies into a baccalaureate nursing curriculum.

The significance of good clinical reasoning skills relates to prevention of adverse patient outcomes from failure to diagnose problems, institute appropriate treatments, and/or manage complications. The clinical reasoning pedagogies described in this article are integrated across a baccalaureate curriculum designed to promote a beginner level of competence in solving patient problems. The faculty adopted the content, structure, and process model for integration that includes professional language and content, the Outcome-Present State Test (OPT) model of clinical reasoning, and reflective journaling. These strategies show promise for attaining higher levels of student thinking, focusing attention on patient problems, and promoting situated cognition. As students realize that situations are complex, faculty guidance can influence best judgments and facilitate clinical reasoning with feedback on assignments to promote student growth and competence in solving clinical problems.The significance of good clinical reasoning skills relates to prevention of adverse patient outcomes from failure to diagnose problems, institute appropriate treatments, and manage complications (Lapkin, Levett-Jones, Bellchambers, & Fernandez, 2010). Since the early 1990s, educators in various health care disciplines have questioned the clinical reasoning abilities of new graduates because of the lack of explicit pedagogies to promote these abilities and the inability to measure outcomes (Boshuizen & Schmidt, 2000; Groves, O'Rourke, & Alexander, 2003; Hoben, Varley, & Cox, 2007; Kabanza, Bisson, Charneau, & Taek-Sueng, 2006; Liu, Chan, & Hui-Chan, 2000; McAllister & Rose, 2000; Norman & Eva, 2010; Rochmawati & Wiechula, 2010; Unsworth, 2001). Research with practicing professionals and students over the past two decades has shown very detailed descriptions of domain-specific clinical reasoning differences between novices and experts, which influenced some of the current educational pedagogies. Some authors suggest that a paradigm shiftin health care education changed the focus from hypothetico- deductive reasoning within the biomedical model (Elstein, Shulman, & Sprafka, 1990) to narrative reasoning, in which truth is related to contextually constructed realities and clinical reasoning exists from multiple perspectives (Benner, et al., 2008; Edwards & Richardson, 2008; Murphy, 2004). For example, the nursing research surrounding cognitive processes has shown difficulty in demonstrating a relationship between nursing outcomes and critical thinking in clinical settings (Murphy, 2004). Clinical reasoning may be a better measure of the cognitive skills nurses use because it includes reflective thinking in practice contexts where individuals create experiential meanings.For the purpose of this article, clinical reasoning is defined as the reflective, concurrent, creative, and critical thinking processes by which nurses collect cues, process information, come to an understanding of patient problems or situations, plan and implement interventions, evaluate outcomes, and reflect to learn from the process (Hoffman, 2007; Levett-Jones et al., 2010; Tanner, Padrick, Westfall, & Putzier, 1987; Pesut & Herman, 1999). The clinical reasoning pedagogies suggested in this paper adhere to this definition, and integration across the baccalaureate curriculum is designed to achieve a novice level of competence in solving patient problems upon graduation and beginning practice.BACKGROUNDNorman (2005) described the evolution of clinical reasoning over three decades starting with the 1970s (the "golden age of problem-solving"): using think-aloud and hypothetico-deductive methods. Learners at all levels of education were assumed to be using the same thinking strategies for decision making, so the thinking process was believed to be related to content knowledge, not to expertise (Simmons, 2010). In the 1980s, gaining expertise was thought to be a process of acquiring a large set of representative cases. …