The think aloud approach as an educational tool to develop and assess clinical reasoning in undergraduate students

Summary

Even though clinical reasoning is attributed with the expert practitioner, there is limited evidence to support methods of teaching and learning that are used to foster its development in nurses. In nursing, a considerable range of teaching and learning strategies are available that can be used to develop clinical reasoning skills. This includes the think aloud seminar. This process oriented method has been successfully used to develop reasoning skills in nursing students [Lee, J.E.M. and Ryan-Wenger, N. 1997. The “think aloud” seminar for teaching clinical reasoning: A case study of a child with pharyngitis. J. Pediatric Health Care 11(1), 105–110.] and is one that should be adopted by nurse educators as a core teaching and learning strategy when educating pre-registration student nurses.

Introduction

Clinical reasoning is an essential feature of health care practice that focuses on the assimilation, analysis and differentiation of health care evidence. This evidence is then applied to selective groups of patients and decisions are made pertinent to their nursing management (Fonteyn et al., 1993, Simmons et al., 2003). Clinical reasoning may be defined as “an inferential process used by practitioners to collect and evaluate data and to make judgments about the diagnosis and management of patient problems” (Lee and Ryan-Wenger, 1997, p. 101). This process is iterative and recursive and a central feature of self-regulated learning. It is proposed that clinical reasoning is a cognitive process which involves both metacognition (reflective thinking) and cognition (thinking); both are inextricably linked and essential components of the reasoning process (Kuiper, 2003, Kuiper and Pesut, 2004).

Metacognition is a term used in educational psychology which refers to higher order thinking and involves the active control of cognitive (thinking) processes and the assessment of to what extent cognitive outcomes have been achieved in relation to learning situations (Flavell, 1987, Wikipedia, 2006). Learning situations may involve planning, monitoring, and evaluating a given task. In general terms, metacognition can be thought of as “thinking about thinking” as it consists of metacognitive regulation or strategies that are used to control or oversee cognitive activities and goals and metacognitive knowledge which may be factual, explicit or implicit (Wikipedia, 2006). Knowledge may be generalised according to personal variables, task or strategic variables (Flavell, 1987). Metacognitive processing will then use these forms of knowledge to participate in cognitive activities to ensure cognitive goals and outcomes are met (Brown, 1987). During this process individuals will use both inductive and deductive logic to simultaneously assemble and evaluate patient information and supportive evidence before making judgements about nursing care (Higgs et al., 2001, Simmons et al., 2003).

The importance of clinical reasoning to nursing practice cannot be underestimated (Simmons et al., 2003). It is proposed that clinical reasoning is an innate feature of nursing that impacts on the provision of carefully planned and executed nursing care (Burns and Higgs, 2000) and is a process that nurses at all levels engage in Fisher and Fonteyn (1995). However, some view clinical reasoning as the hallmark of the nursing expert (Fowler, 1997) which can be used to distinguish the expert from the novice nurse (Junnola et al., 2002). Clinical reasoning is composed of several subcomponents; intuition, domain-specific knowledge and experience (Benner and Tanner, 1997, Crow et al., 1995, Parker et al., 1999). Each of these components can be used to enhance the quality of care provided to patients using a process that involves “applying knowledge and expertise to a clinical situation to develop a solution” (Carr, 2004, p. 851).

Although numerous nursing research studies have explored the concept of clinical reasoning (Fowler, 1997, Bucknall, 2003, Kuiper, 2003, Kuiper and Pesut, 2004, Carr, 2004) there is no consensus on the definition, characteristics or subcomponents or the methods that should be employed by nurse educators to teach clinical reasoning to pre-registration nursing students. The aim of this paper is to examine the use of the think aloud approach as an exemplar of a teaching and learning strategy that can be employed to develop nurses’ ability to clinically reason.