Debriefing to nurture clinical reasoning in nursing students: A design-based research study

The objective of this review was to determine whether the use of Personal Digital Assistants (PDAs) would provide greater support in developing undergraduate nursing students' clinical reasoning, in comparison to more traditional resources such as textbooks. The search strategy sought to identify published data from five electronic databases: CINAHL, Medline, Cochrane Library, Meditext and Scopus. Unpublished literature was also sought in digital dissertations, conference proceedings, relevant scholarly websites and reference lists. All undergraduate nursing students were considered eligible for inclusion. Types of interventions considered for this review were inclusive of all forms of PDAs and traditional resources. The research setting of this systematic review reflects the diversity of nursing practice, and includes the classroom, clinical or simulated environment. The process of clinical reasoning was defined by four outcome measures; alterations in theoretical nursing knowledge, clinical skills, problem solving and reflection. Studies of potential significance to the review were assessed for methodological quality independently by two reviewers using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. Authorship of the studies was not concealed from the two reviewers. From the nine studies assessed for quality, only data from four studies were included in the review. Four published studies were included in the systematic review of literature. The designs of the studies included a nonrandomised quasi-experimental design, case control study, comparative descriptive design and a pre test post test mixed method study. Four outcomes were identified by the four included studies. These outcomes addressed possible effects of PDA usage on undergraduate nursing students' practice of medication administration, self-efficacy, anticipation to exercise professional nursing judgment and clinical reasoning.This systematic review provides evidence that the use of PDAs is able to improve nursing students' self-efficacy and accuracy in clinical situations that require direct and context-free answers, such as medication administration, but is not as supportive as textbooks in assisting students to apply this knowledge critically in decision making and problem solving. The use of PDAs by undergraduate nursing students can improve students' confidence in the often stressful clinical environment. This bears significance in contemporary nursing education where undergraduates are failing to maximise the clinical experience because of insufficient support or guidance from busy clinicians or supervisory staff. From these findings, PDAs are also beneficial in improving the accuracy and efficiency of medication administration in nursing students. However, the application of the knowledge provided by PDAs is not supported to be used critically in its application to decision making and problem solving. Nursing students need to be educated in methods to develop critical analysis in order to use these resources effectively. This systematic review highlights the poor quantity of literature currently available in nursing and the subsequent need for primary quantitative studies examining the effect of PDAs in developing undergraduate nursing students' clinical reasoning skills.

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...

[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.

Challenges nurse educators experience with development of student nurses’ clinical reasoning skills

Designing for online computer-based clinical simulations: Evaluation of instructional approaches

Review question/objective The overall aim of this systematic review is to identify the appropriateness and meaningfulness of maternal-child simulation-based learning for undergraduate or pre-registration nursing students in educational settings to inform curriculum decision-making. 1. What are the experiences of nursing or health professional students participating in undergraduate or pre-licensure maternal-child simulation-based learning in educational settings? 2. What are the experiences of educators participating in undergraduate or pre-licensure maternal-child simulation-based learning in educational settings? 3. What teaching and learning practices in maternal-child simulation-based learning are considered appropriate and meaningful by students and educators? Inclusion criteria Types of participants Participants will include undergraduate or pre-registration or pre-licensure nursing or midwifery or health professional students and educators participating in maternal-child simulation-based learning. Midwifery or undergraduate medical students are included as participants as their clinical learning experiences are similar to undergraduate nursing students. However students in graduate, postgraduate, or specialty education programs and practising nurses or other health care professionals (continuing education) will be excluded from this review because the purpose is to identify the implications for undergraduate or pre-registration nursing programs. Undergraduate or pre-registration education differs from continuing professional education as students are more likely to be learning this way of thinking or clinical reasoning for the first time. The pedagogical approaches used also differ from continuing professional development. Phenomena of interest This review will consider studies that investigate simulation-based learning experiences that are relevant to maternal-child nursing. Our primary interest in this review is in preparing nursing students for senior level maternal-child practice placements and transition to working as an Registered Nurse. However, we will include all qualitative studies and case reports of simulation-based learning that involve pre-registration nursing or health professional students. Context The purpose of this review is to identify the implications of this body of knowledge for undergraduate or pre-registration nursing programs in Canada This review will include qualitative research that may be applicable to the Canadian context for nursing education, such as reports from North America, Europe, Australia and New Zealand.

BackgroundNursing students often experience high anxiety and depression because of the demanding nursing curriculum. This mental strain can harm their academic performance. As a result, nurse educators need to assess how anxiety impacts nursing students’ academic achievements.ObjectivesTo evaluate and describe the knowledge of counsellors and nurse educators regarding the impact of anxiety-related conditions on nursing students’ academic excellence in selected nursing education institutions.MethodA qualitative descriptive phenomenological design was used to evaluate and describe the perceptions of counsellors and nurse educators about anxiety-related conditions on nursing students’ academic excellence. Participants were purposively selected, and semi-structured interviews were utilised to collect data. Four counsellors involved in psychosocial support of nursing students who participated in individual semi-structured interviews, and 20 nurse educators participated in focus group interviews, with 5 participants per group. Data were recorded and transcribed. Transcripts were analysed using Giorgi’s (2009) four data analysis steps.ResultsFour themes emerged from data analysis: understanding of anxiety-related conditions, responses to anxiety-related conditions, influences of anxiety-related conditions and support of nursing students with anxiety-related conditions. The findings highlighted the significance of recognising the effects of mental health issues on nursing students.ConclusionThe study revealed the factors influencing nursing students’ responses to and the support provided for anxiety-related conditions affecting their academic performance.ContributionThe importance of prioritising mental health support for nursing students is to ensure they complete their qualifications on time.

Development and psychometric testing of a Clinical Reasoning Evaluation Simulation Tool (CREST) for assessing nursing students' abilities to recognize and respond to clinical deterioration

To provide depth and breadth in the analysis of nursing students' written narratives of 'most memorable' professionalism dilemmas. While nursing students are taught professionalism through formal curricula, they commonly experience workplace-based professionalism dilemmas. Although non-UK studies have begun to explore students' lived experiences of dilemmas, they lack detail about when and where dilemmas occur, who is involved, what students do and why and how students feel. Online survey of healthcare students including 294 nursing students from 15 UK nursing schools. Nursing students provided a written narrative of their most memorable dilemma (December 2011-March 2012) as part of a survey examining the impact of professionalism dilemmas on moral distress. We conducted thematic and discourse analysis of all narratives and narrative analysis of one exemplar. The most common themes were patient care dilemmas by healthcare personnel or students, student abuse and consent dilemmas. Of the dilemmas, 49·6% occurred over 6months previously, 76·2% occurred in hospitals and 51·9% of perpetrators were nurses. 79·3% of students reported acting in the face of their dilemma. Of the narratives, 88·4% contained negative emotion talk and numerous significant relationships existed between types of emotion talk and dilemmas. Our narrative analysis demonstrates the impact of dilemma experiences through emotion talk and more subtle devices like metaphor. Findings extend previous research with nursing and medical students. Nurse educators should help students construct emotionally coherent narratives to make sense of their experiences, actions and identities and to better prepare them for future professionalism dilemmas.

PurposeGraduating medical students need broad clinical diagnostic reasoning skills that integrate learning across clinical specialties to deal with undifferentiated patient problems. The opportunity to acquire these skills may be limited during clinical placements on increasingly specialized hospital wards. We developed an intervention of regular general practitioner (GP) facilitated teaching in hospital placements to enable students to develop broad clinical diagnostic reasoning. The intervention was piloted, refined and delivered to a whole cohort of medical students at the start of their third year. This paper examines whether students perceived opportunities to improve their broad diagnostic clinical reasoning through our intervention.MethodsGP-facilitated teaching sessions were delivered weekly in hospital placements to small groups of 6–8 students for 90 mins over 6 weeks. Students practiced clinical reasoning with real patient cases that they encountered on their placements. Evaluation of learning outcomes was conducted through a student questionnaire using Likert scales with free-text boxes for additional explanation. Focus groups were conducted to gain a more in-depth understanding of student perspectives.ResultsAs high as 87% of students agreed that their broad clinical diagnostic reasoning ability had improved. Thematic analysis of the qualitative data revealed four factors supporting this improvement: practicing the hypothetico-deductive method, using real patient cases, composing student groups from different speciality placements and the breadth of the facilitators’ knowledge. Students additionally reported enhanced person-centredness in terms of understanding the patient’s perspective and journey. Students perceived that the added value of general practitioner facilitators lay in their broad knowledge base and knowledge of patient needs in the community.ConclusionOur results suggest that medical students can develop broad clinical diagnostic reasoning skills in hospital settings through regular GP-facilitated teaching. Our approach has the advantage of working within the established curricular format of hospital placements and being deliverable at scale to whole student cohorts.

Clinical reasoning is a topic that has received significant attention over the last decade, within both the academic and clinical communities. The numerous and varied publications in the Journal of Physical Therapy Education (JOPTE) reflect the profession's interest in studying clinical reasoning in physical therapy education and practice.In this issue, 4 papers address the topic of clinical reasoning. Drs Huhn and Parrott present a research report exploring the use of the Health Sciences Reasoning Test (HSRT) and academic measures (GPA and GRE scores) at the time of admission to predict physical therapist (PT) student success on the NPTE.1 This paper builds on Dr Huhn's prior work examining the utility of the HSRT in demonstrating development of critical thinking skills across PT education programs.2 Drs Venskus and Craig have developed and validated a tool to measure the degree of self-efficacy with respect to the development of clinical reasoning skills reported by PT students. This paper adds to the growing body of literature about the development of clinical reasoning, specifically addressing the student's capability to reason.3The other 2 papers in this issue are research reports that explore the development of clinical reasoning abilities. Dr. Gilliland has applied qualitative research methods to explore the development of diagnostic reasoning in PT students. She employed think aloud processes using a musculoskeletal paper case at 2 points in the students entry-level PT education to identify evolution of diagnostic reasoning.4 Drs Trommelen, Karpinski, and Chauvin studied the effectiveness of a novel instructional activity to promote reflection in a case-based delivery model for neuromuscular physical therapy.5 Like Drs Huhn and Parrott, these authors used standardized measures (the Diagnostic Thinking inventory and the Self-Assessment of Clinical Reasoning Tool) to demonstrate improvement in the student's clinical reasoning and reflective abilities. One of the challenges in conducting and applying this research is the varied methods and assessment tools that are used in studying clinical reasoning.Study of clinical reasoning in PT students has demonstrated that clinical reasoning abilities develop over time within PT curricula.6,7 Research on expertise has demonstrated the continued development of these clinical reasoning abilities beyond formal entry-level education. For example, a study of promising novices over a 2-year period as they entered practice indicated ongoing development and subsequent expansion and refinement of formal and informal learning, clinical skills, and collaboration.8 Findings such as these indicate the importance of creating opportunities to develop clinical reasoning skills as a student and novice practitioner.Another area of study in clinical reasoning has been the development of rubrics to assess clinical reasoning during practical assessment of student's clinical knowledge and skill performance. Two such assessment tools have been reported in JOPTE. The Think Aloud Standardized Patient Examination (TASPE)9 was developed to assess clinical reasoning competency in novice physical therapy students during standardized musculoskeletal patient encounters. Using the TASPE, students are assessed on their ability to synthesize data to inform think-aloud sessions across the hypothetico-deductive reasoning process: hypothesis generation, hypothesis evaluation, and intervention. A second tool, the Clinical Reasoning Grading Rubric, 10 has 2 intended purposes: (1) assess the clinical reasoning skills of PT students, and (2) evaluate readiness to progress to full-time clinical education. This tool incorporates assessment across cognitive, psychomotor, and affective domains with criteria from low to high performance of knowledge, skills, and attitudes.Another category of study is the development of skills that are components of clinical reasoning. Several studies exploring the development of critical thinking have been published in JOPTE over that past few years. …

This qualitative phenomenological study examined the perceptions and lived experiences of traditional undergraduate nursing students who encountered stress and anxiety within clinical settings. These emotional challenges are common among nursing students, especially in clinical settings, where they can negatively affect well-being, hinder learning, and even contribute to attrition from nursing programs. The study sought to explore the factors that contribute to these emotional responses, identify self-care strategy utilization, assess their perceptions of faculty and curricular support for self-care, in addition to understanding how they view the role of self-care in their future professional roles. The study was conducted at an accredited four-year university in the Mid-Atlantic region of the United States and involved semi-structured, one-on-one interviews with senior-level Bachelor of Science in Nursing (BSN) students who had reported experiencing stress or anxiety in clinical settings. Data was analyzed and coded to extract recurring themes from participant narratives. Findings revealed that stress and anxiety levels varied across clinical settings, influenced by factors such as client populations and setting-specific demands. Key stressors included academic workload, particularly time-consuming documentation tasks like care plans and concept maps. Inconsistent expectations and support from clinical instructors and preceptors also emerged as major contributors to student stress and diminished confidence. Participants reported using a range of coping strategies, including taking brief mental breaks, practicing positive self-talk, and seeking support from peers or faculty. Although students universally recognized the importance of self-care, many expressed difficulties maintaining it consistently due to academic pressures and a perceived lack of meaningful support or emphasis from the nursing curriculum and faculty. The study concludes that creating psychologically safe learning environments and embedding practical, accessible self-care support within nursing education are critical for improving student well-being, fostering resilience, and preparing graduates for sustainable professional practice. Recommendations include re-evaluating documentation expectations and strengthening both formal and informal support systems within nursing programs. Keywords: self-care, stress, anxiety, nursing students, clinical settings.

An integrative review of simulation, senior practicum and readiness for practice

Problem-Based Learning (PBL) has emerged as a promising strategy for teaching Evidence-Based Practice (EBP) to nursing and midwifery professionals. However, its effectiveness remains insufficiently synthesized, with few studies directly addressing its impact on EBP competencies. To systematically review and synthesize evidence on the efficacy of Problem-Based Learning as a teaching approach for developing Evidence-Based Practice competencies among nursing and midwifery students and professionals. This systematic review with narrative synthesis was conducted in accordance with the Cochrane Handbook and reported following PRISMA 2020 guidelines. The protocol was registered in PROSPERO (CRD42023390989). A comprehensive search of MEDLINE, CINAHL, PubMed, EMBASE, Web of Science, ERIC, PsycINFO, and Cochrane CENTRAL was performed from inception through August 2025. Two reviewers independently screened and appraised studies using JBI-SUMARI tools and ROBINS-I. Eighteen studies met inclusion criteria, but only three (16.7%) specifically examined PBL for EBP education among nursing students in Iran, Japan, and South Korea. These consistently demonstrated significant improvements in knowledge, attitudes, critical thinking, and clinical decision-making compared with traditional methods, with all rated at low risk of bias. Broader EBP education studies reported highly variable implementation rates (13–100%), with higher educational levels linked to greater uptake of evidence-based behaviours. Across studies, factors supporting success included adequate time, access to technological resources, faculty preparation, and organizational support. Common barriers were limited infrastructure, faculty workload, and students’ initial resistance to active learning. Preliminary evidence suggests PBL enhances EBP-related competencies, but the current evidence base is small, heterogeneous, and lacks midwifery-specific studies. Rigorous comparative research using standardized outcomes and evaluating long-term practice impact is needed to establish optimal strategies for integrating PBL into nursing and midwifery education.

ABSTRACTProblem: Clinical reasoning is a necessary skill for medical students to acquire in the course of their education, and there is evidence that they can start this process at the undergraduate level. However, physician educators who are experts in their given fields may have difficulty conveying their complex thought processes to students. Providing faculty development that equips educators with tools to teach clinical reasoning may support skill development in early medical students. Intervention: We provided faculty development on a modified Bayesian method of teaching clinical reasoning to clinician educators who facilitated small-group, case-based workshops with 2nd-year medical students. We interviewed them before and after the module regarding their perceptions on teaching clinical reasoning. We solicited feedback from the students about the effectiveness of the method in developing their clinical reasoning skills. Context: We carried out this project during an institutional curriculum rebuild where clinical reasoning was a defined goal. At the time of the intervention, there was also increased involvement of the Teaching and Learning Center in elevating the status of teaching and learning. Outcome: There was high overall satisfaction with the faculty development program. Both the faculty and the students described the modified Bayesian approach as effective in fostering the development of clinical reasoning skills. Lessons Learned: Through this work, we learned how to form a beneficial partnership between a clinician educator and Teaching and Learning Center to promote faculty development on a clinical reasoning teaching method for early medical students. We uncovered challenges faced by both faculty and early learners in this study. We observed that our faculty chose to utilize the method of teaching clinical reasoning in a variety of manners in the classroom. Despite obstacles and differing approaches utilized, we believe that this model can be emulated at other institutions to foster the development of clinical reasoning skills in preclerkship students.