Clinical Nursing Reasoning in Nursing Practice: A Cognitive Learning Model Based on a Think Aloud Methodology

BackgroundClinical reasoning is fundamental to all forms of professional health practice, however it is also difficult to teach and learn because it is complex, tacit, and effectively invisible for students. In this paper we present an approach for teaching clinical reasoning based on making expert thinking visible and accessible to students.MethodsTwenty-one experienced allied health clinical educators from three tertiary Australian hospitals attended up to seven action research discussion sessions, where they developed a tentative heuristic of their own clinical reasoning, trialled it with students, evaluated if it helped their students to reason clinically, and then refined it so the heuristic was targeted to developing each student’s reasoning skills. Data included participants’ written descriptions of the thinking routines they developed and trialed with their students and the transcribed action research discussion sessions. Content analysis was used to summarise this data and categorise themes about teaching and learning clinical reasoning.ResultsTwo overriding themes emerged from participants’ reports about using the ‘making thinking visible approach’. The first was a specific focus by participating educators on students’ understanding of the reasoning process and the second was heightened awareness of personal teaching styles and approaches to teaching clinical reasoning.ConclusionsWe suggest that the making thinking visible approach has potential to assist educators to become more reflective about their clinical reasoning teaching and acts as a scaffold to assist them to articulate their own expert reasoning and for students to access and use.

[Extract] Clinical reasoning may be defined as the cognitive processes involved in arriving at a diagnosis or treatment plan. It is central to effective medical practice, yet it remains elusive and continues to present a challenge to clinical teachers and learners. The antemortem misdiagnosis rate at autopsies and audits of adverse events in hospitals attest to the continuing importance of clinical reasoning, despite the introduction of guidelines and advances in technology. The level of quality and accuracy of the clinical reasoning that underlies diagnostic and management decisions is the difference between trainees and expert clinicians. The process of learning clinical reasoning may be assisted by using think aloud.

BackgroundWhile educational techniques to improve clinical reasoning (CR) skills among medical students have been developed, the lack of faculty expertise in teaching CR remains a significant barrier.1 Teaching the teachers...

Introduction An objective of undergraduate medical education is to teach students how to think like physicians through a process called clinical reasoning. Currently, clerkship directors often feel that students enter their clinical years with a marginal comprehension of clinical reasoning concepts; instruction in this area could be improved. Although there have been previous educational studies assessing curricular interventions to improve the instruction of clinical reasoning, it is not yet known what happens at an individual level between an instructor and a small group of students in the teaching of clinical reasoning. This research will identify how clinical reasoning is being taught in a longitudinal clinical reasoning course. Methods The Introduction to Clinical Reasoning course is a 15-month-long case-based course held in the preclinical curriculum of the USU. Individual sessions involve small-group learning with approximately seven students per group. Throughout the academic year of 2018-2019, 10 of these sessions were videotaped and transcribed. All participants provided informed consent. A thematic analysis was performed using a constant comparative approach. Transcripts were analyzed until thematic sufficiency was reached. Results Over 300 pages of text were analyzed; new themes ceased to be identified after the eighth session. Topics included obstetrics, general pediatric issues, jaundice, and chest pain; these sessions were taught either by attendings, fellows, or fourth-year medical students with attending supervision. The thematic analysis revealed themes associated with clinical reasoning processes, themes associated with knowledge organization, and a theme associated with clinical reasoning in the military. The clinical reasoning process themes included problem list construction and refinement, differential diagnosis, naming and defending a leading diagnosis, and clinical reasoning heuristics. The knowledge organization themes included illness script development and refinement and semantic competence. The final theme was military relevant care. Conclusions In individual teaching sessions, preceptors emphasized problem lists, differential diagnoses, and leading diagnoses in a course designed to strengthen diagnostic reasoning in preclerkship medical students. The use of illness scripts was more often implicitly used rather than explicitly stated, and students used these sessions to use and apply new vocabularies related to a clinical presentation. Instruction in clinical reasoning could be improved by encouraging faculty to provide further context to their thinking, by encouraging the comparing and contrasting of illness scripts, and by using a shared vocabulary for clinical reasoning. Limitations of this study include that it was done in the context of a clinical reasoning course and that it was done at a military medical school, which may limit generalizability. Future studies could determine if faculty development could improve the frequency of references to the clinical reasoning processes that could improve student readiness for clerkship.

Clinical reasoning processes involve gathering and interpreting information, creating differential diagnoses and testing hypotheses to inform and guide patient management. Effective clinical reasoning is an essential graduate outcome for medical students to ensure safe and efficient care of patients. In the clinical setting, a large proportion of hospital-related adverse events are attributed to errors in cognitive processes rather than knowledge, including diagnostic reasoning and decision-making. Teaching clinical reasoning is challenging due to its implicit nature, typically relying on internal thinking processes, pattern recognition and the use of prior clinical experiences. Current conventional teaching relies on student-driven application of clinical reasoning during their rotations as part of a hidden curriculum, which can be highly variable, unstructured, non-standardised, with limited oversight from faculty and with few opportunities for feedback. Furthermore, current barriers exist, including difficulties in teaching and assessing clinical reasoning. Due to this, many educators and faculty agree upon the significance of embedding explicit teaching and assessment of clinical reasoning into the curriculum, however the best approach remains poorly characterised. A narrative synthesis was undertaken from the current literature and the authors' collective experience. The synthesis distils this information into ten practical tips to guide design, integration and innovation of clinical reasoning teaching in medical education. Ten tips were identified to support educators' efforts in embedding clinical reasoning into curriculum design and teaching. Together, these ten tips promote explicit, reflective and contextual clinical reasoning learning within the contemporary medical curriculum. Clinical reasoning requires deliberate, longitudinal and student-centred approaches that are integrated within authentic situated learning experiences. The ten tips provide avenues for more evidence-based adoption of effective learning environments that focus on clinical reasoning skills development.

Clinical reasoning teaching is an approach educational method based on learning and contextualized and synthesis education. The aim of this study was to determine the value of clinical reasoning teaching sessions, from the perspective of third year medical students using a self-administered questionnaire. One group of ten students participated in this study. They had clinical case sessions during three weeks. An anonymous evaluation self-administered questionnaire was submitted to the students at the end of the period. The average scores given by students for the items “quality of education”, “atmosphere”, “interest in teaching sessions” and “acquisition of new clinical knowledge” were greater than 7/10. All students opted for clinical reasoning teaching as the preferred teaching method for optimal memorization and have found a real contribution of reasoning teaching in the management of relationship with the patient. Clinical reasoning teaching session appears to be widely desired by medical students.

Background The cognitive pathways that lead to an accurate diagnosis and efficient management plan can touch on various clinical reasoning tasks (1). These tasks can be employed at any point during the clinical reasoning process and though the four distinct categories of framing, diagnosis, management, and reflection provide some insight into how these tasks map onto clinical reasoning, much is still unknown about the task-based clinical reasoning process. For example, when and how are these tasks typically used? And more importantly, do these clinical reasoning task processes evolve when patient encounters become complex and/or challenging (i.e. with contextual factors)? Methods We examine these questions through the lens of situated cognition, context specificity, and cognitive load theory. Sixty think-aloud transcripts from 30 physicians who participated in two separate cases - one with a contextual factor and one without - were coded for 26 clinical reasoning tasks (1). These tasks were organized temporally, i.e. when they emerged in their think-aloud process. Frequencies of each of the 26 tasks were aggregated, categorized, and visualized in order to analyze task category sequences. Results We found that (a) as expected, clinical tasks follow a general sequence, (b) contextual factors can distort this emerging sequence, and (c) the presence of contextual factors prompts more experienced physicians to clinically reason similar to that of less experienced physicians. Conclusions These findings add to the existing literature on context specificity in clinical reasoning and can be used to strengthen teaching and assessment of clinical reasoning.

Clinical reasoning is essential to medical practice, but because it entails internal mental processes, it is difficult to assess. Functional magnetic resonance imaging (fMRI) and think-aloud protocols may improve understanding of clinical reasoning as these methods can more directly assess these processes. The objective of our study was to use a combination of fMRI and think-aloud procedures to examine fMRI correlates of a leading theoretical model in clinical reasoning based on experimental findings to date: analytic (i.e., actively comparing and contrasting diagnostic entities) and nonanalytic (i.e., pattern recognition) reasoning. We hypothesized that there would be functional neuroimaging differences between analytic and nonanalytic reasoning theory. 17 board-certified experts in internal medicine answered and reflected on validated U.S. Medical Licensing Exam and American Board of Internal Medicine multiple-choice questions (easy and difficult) during an fMRI scan. This procedure was followed by completion of a formal think-aloud procedure. fMRI findings provide some support for the presence of analytic and nonanalytic reasoning systems. Statistically significant activation of prefrontal cortex distinguished answering incorrectly versus correctly (p < 0.01), whereas activation of precuneus and midtemporal gyrus distinguished not guessing from guessing (p < 0.01). We found limited fMRI evidence to support analytic and nonanalytic reasoning theory, as our results indicate functional differences with correct vs. incorrect answers and guessing vs. not guessing. However, our findings did not suggest one consistent fMRI activation pattern of internal medicine expertise. This model of employing fMRI correlates offers opportunities to enhance our understanding of theory, as well as improve our teaching and assessment of clinical reasoning, a key outcome of medical education.

Errors in clinical reasoning continue to account for significant morbidity and mortality, despite evidence-based guidelines and improved technology. Experts in clinical reasoning often use unconscious cognitive processes that they are not aware of unless they explain how they are thinking. Understanding the intuitive and analytical thinking processes provides a guide for instruction. How knowledge is stored is critical to expertise in clinical reasoning. Curricula should be designed so that trainees store knowledge in a way that is clinically relevant. Competence in clinical reasoning is acquired by supervised practice with effective feedback. Clinicians must recognise the common errors in clinical reasoning and how to avoid them. Trainees can learn clinical reasoning effectively in everyday practice if teachers provide guidance on the cognitive processes involved in making diagnostic decisions.

<i>Learning Clinical Reasoning</i>... even the title seems different. The book is unlike any of the standard texts on decision making. It starts with 10 short chapters on the key processes of clinical reasoning. The bulk of the book follows, consisting of clinical examples demonstrating these processes. Given the authors' specialty, it is not surprising that the cases concentrate in internal medicine, but the processes described are universal and therefore useful for all clinicians. The clinical examples are not the standard case report nor are they presented in the typical clinical-pathological conference format. Instead Drs Kassirer and Kopelman present the first few sentences of the case history followed by an "expert's" response. More of the case is presented, and again the expert responds. As the case unfolds, the expert modifies his or her comments. At the end of each case, the authors present their views on the clinical reasoning process, and

A mental model is a student's perception or description of a concept. Chemistry learning requires deep understanding including three levels of representation; macroscopic, sub-microscopic, and symbolic. These three levels of representation are interconnected to form a meaningful understanding and students' mental model. The purpose of this study was to look at the mental models of students on acid and base topic taught using cognitive apprenticeship learning model. This research employed explanatory sequential mix method with 65 research subjects. The research instrument was in the form of a description test of acid-base concepts and an interview guideline for the students’ answers on the test. The results showed that students had good mental models (63.64%) on acid and base taught using cognitive apprenticeship learning model.

Self-Explanation, An Instructional Strategy to Foster Clinical Reasoning in Medical Students

BackgroundStudents' clinical reasoning can be stimulated by guiding them to use their experiences with patients to develop own illness scripts. Debriefing during hospital shifts invites students to put patient experiences into words, link them to previously acquired knowledge and make connections. ObjectivesTo develop, implement and evaluate a debriefing procedure for nursing internships based on illness script theory and generate corresponding design principles. DesignQualitative design-based research. SettingClinical education in dedicated educational hospital units. ParticipantsNurse educators, nursing students. MethodsFrom a collaboration between nurse educators and a researcher, a short, peer-debriefing procedure was designed, tested and enacted through four cycles of planning, action, evaluation and reflection. Students drew mind maps about patients. Nurse educators and students joined focus group discussions to evaluate outcomes and processes. Mind map and iterative thematic analysis were applied to these data. ResultsAn adjusted design and more extensive design principles resulted. Differences in mind maps were evident over time. Three themes in the process evaluation were established: trigger to reason; energy giving and taking; and form follows function. ConclusionsThis design-based investigation displays how nurse educators could design and implement a debriefing procedure to facilitate students' clinical reasoning skills and how students could learn from this. This method integrates research, innovation and collaboration. The design and enactment under real-life hospital conditions generated design principles for educators and researchers which may be useful for those seeking to improve teaching and learning clinical reasoning in practice. More clarification is needed about the path from design through enactment to real change in practice.

Learning by playing: A cross-sectional descriptive study of nursing students' experiences of learning clinical reasoning

The purpose of the study was to measure the impact of the application of cognitive learning theory on the spirit of learning, as well as integrate qualitative and quantitative approaches to gain a holistic understanding. This study used a quasi-experimental design with two groups of students as research subjects, where the experimental group received an intervention with a cognitive learning model, while the control group followed conventional learning. Data was collected through pre-test, post-test, and spirit of learning questionnaires. Data analysis involves T test for quantitative data and thematic analysis for qualitative data. The results showed a significant increase in the enthusiasm of students who followed the cognitive learning model, along with positive changes in students' perceptions and experiences of science learning.