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Collins M, Probst H, Grafton K. Decision-making processes in image guided radiotherapy: A think aloud study. J Med Imaging Radiat Sci 2023; 54:707-718. [PMID: 37852920 DOI: 10.1016/j.jmir.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 09/27/2023] [Accepted: 09/29/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION 3D Image Guided Radiotherapy (IGRT) using Cone Beam Computer Tomography (CBCT) has been implemented for a range of treatment sites across the UK in the last decade. A paucity of evidence exists to understand how radiation therapists (RTTs) make clinical decisions during image interpretation as part of the IGRT process. The aim of this study was to investigate the decision-making processes used by RTTs during image interpretation of IGRT. METHOD Case study methodology was adopted utilising a think aloud observational method with follow-up interviews. 12 RTTs were observed and interviewed across three UK radiotherapy centres. Participants were observed reviewing and making clinical decisions in a simulated environment using clinical scenarios developed in partnership with each centres' Clinical Imaging Lead. Protocol analysis was used to analyse the observational data and thematic analysis was used to analyse the interview data. RESULTS A range of approaches to decision-making was observed which varied in length from nine phrases to 57 (mean 24) per case. Six themes emerged from the data: Set Sequence, Site Specific Clinical Priorities, Initial Gross Review, Decision to treat, Compromise and experience. In addition, three cognitive decision-making processes were identified: Simple linear, Linear repeating and Intuitive decision-making process. The findings of the study align with general principles of expert performance, whereby experience in a specific scope of practice is more beneficial in developing expertise than overall experience. CONCLUSION This study has provided new and original insight in the decision-making processes of RTTs. The study has highlighted three process models to explain how RTTs make decisions during IGRT: Simple linear, Linear repeating and Intuitive decision-making process. Intuitive processes are widely accepted to be error prone and linked to bias. When using this process, some RTTs followed this with a confirmation phase. This second phase of the process should be encouraged when teaching IGRT. The results of the study support the concept of expert performance, where performance and expertise are only improved by exposing individuals to specific types of experiences. RTTs, managers and Higher Education Institutions are encouraged to review these models and implement them into IGRT training. It is clear from the evidence base that understanding how we make decisions, enables us to develop expertise and reduce errors during the decision-making process.
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Affiliation(s)
- Mark Collins
- College of Health Wellbeing & Life Sciences, Sheffield Hallam University, Sheffield S10 2BP, UK.
| | - Heidi Probst
- College of Health Wellbeing & Life Sciences, Sheffield Hallam University, Sheffield S10 2BP, UK
| | - Kate Grafton
- School of Health & Social Care, University of Lincoln, Lincoln LN6 7TS, UK
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Griffits S, Hines S, Moloney C. Characteristics and processes of registered nurses' clinical reasoning and factors relating to the use of clinical reasoning in practice: a scoping review. JBI Evid Synth 2023; 21:713-743. [PMID: 36730096 DOI: 10.11124/jbies-21-00373] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this review was to examine the characteristics and processes of clinical reasoning used by registered nurses in clinical practice, and to identify factors reported to relate to the use of clinical reasoning by registered nurses in clinical practice. INTRODUCTION Significant variability in the clinical reasoning of graduate registered nurses has been identified in research, with underdeveloped and unsafe clinical reasoning being linked to failure-to-rescue and sentinel events in the clinical setting. The identification of characteristics and processes of clinical reasoning, and factors relating to registered nurses' clinical reasoning when engaged in clinical practice, will increase understanding of the clinical reasoning requirements for undergraduate registered nurses and of potential factors that may affect their clinical reasoning. INCLUSION CRITERIA Studies including registered nurses who met the criteria for registered nurse registration in Australia and who used clinical reasoning to engage with health care consumers in all practice environments were eligible for inclusion. METHODS Eight databases were searched, with articles identified through CINAHL, MedNar, PubMed, Science Direct, ERIC, PsycINFO, Scopus, and ProQuest Dissertations and Theses. Database searches were conducted on December 31, 2020, and updated August 20, 2021, with primary qualitative and quantitative research studies in English from 2000 onwards considered for inclusion. Opinion papers, text, and reports were not included. Data were extracted based on the draft charting tool from the scoping review protocol, with results presented in tabular format and in a narrative summary. RESULTS The 29 qualitative and 5 quantitative research studies included in the scoping review utilized exploratory descriptive, descriptive rationalist, narrative, ethnography, correlational, observational, and grounded theory methodologies in their research designs. Observation, think-aloud sessions, questionnaires, surveys, interviews, and focus groups were used to collect data from the 1099 participants in 9 countries. Multiple concepts related to the characteristics (n=35) and processes (n=30) of clinical reasoning were detected in the research studies, with 5 categories identified: i) situation management, ii) data management, iii) interpreting, iv) implementing and evaluating, and v) professional practice, with an additional processes category identified (decision-making processes). The factors (n=26) reported to relate to clinical reasoning were categorized into environment of care, care requirements, professional practice, experience, knowledge, and decision-making processes. Connections between the various concepts were evident throughout the review. CONCLUSIONS The scoping review identified characteristics and processes of clinical reasoning, as well as factors reported to relate to clinical reasoning in all studies. The concepts that comprise the clinical reasoning of registered nurses in clinical practice must be considered in undergraduate registered nurse education. Registered nurses must complete their baccalaureate program with well-developed clinical reasoning to ensure safe clinical practice. Understanding the characteristics and processes of registered nurses' clinical reasoning in clinical practice, and the factors reported to relate to clinical reasoning, supports the creation of targeted resources for development and assessment of clinical reasoning.
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Affiliation(s)
- Susan Griffits
- School of Nursing and Midwifery, Faculty of Health Engineering and Sciences, University of Southern Queensland, Toowoomba, QLD, Australia
| | - Sonia Hines
- College of Medicine and Public Health, Flinders Rural and Remote SA and NT, Alice Springs, NT, Australia
- Mparntwe Centre for Evidence in Health, Flinders University: A JBI Centre of Excellence, Alice Springs, NT, Australia
| | - Clint Moloney
- School of Nursing and Midwifery, Faculty of Health Engineering and Sciences, University of Southern Queensland, Toowoomba, QLD, Australia
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Abdulmohdi N, Mcvicar A. Investigating the clinical decision-making of nursing students using high-fidelity simulation, observation and think aloud: A mixed methods research study. J Adv Nurs 2023; 79:811-824. [PMID: 36412270 PMCID: PMC10099619 DOI: 10.1111/jan.15507] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 10/14/2022] [Accepted: 11/08/2022] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to investigate nursing students' clinical decision-making by using high-fidelity simulation of a deteriorated patient scenario. DESIGN A convergent parallel mixed methods research design was used consisting of quantitative and qualitative data collection. METHODS Twenty-three students completed the Health Science Reasoning Test before and after the simulation between October 2015 and June 2016. They were presented with a simulated scenario and asked to 'think aloud' during and after the simulation. The students were audio-video recorded and observations were collected by the researcher. RESULTS There was a significant moderate increase in the 'deduction' and 'analysis' sub-scale scores and overall test score, suggestive of improved analytical decision-making processes through the simulation experience. Think-aloud and observation data identified that students predominantly applied 'forward' reasoning during the simulated 'patient's' deterioration, focusing mainly on cue acquisition. 'Backward' reasoning with a focus on cue interpretation was most prominent in the debriefing data, in line with the survey outcomes. Accurate cue interpretation of critical, key cues appeared more useful than the total number of cues in solving the main clinical case problem. CONCLUSION Students learn different clinical decision-making skills during the simulation compared to what they learn from debriefing. Using observation and think-aloud methods have significant benefits for researchers seeking to optimize the evaluation of the clinical decision-making process.
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Affiliation(s)
- Naim Abdulmohdi
- School of Nursing and Midwifery, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Cambridge, UK
| | - Andrew Mcvicar
- School of Nursing and Midwifery, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Chelmsford, UK
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Community pharmacists’ clinical reasoning: a protocol analysis. Int J Clin Pharm 2019; 41:1471-1482. [DOI: 10.1007/s11096-019-00906-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 09/07/2019] [Indexed: 10/26/2022]
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Holder AG. Clinical Reasoning: A State of the Science Report. Int J Nurs Educ Scholarsh 2018; 15:/j/ijnes.2018.15.issue-1/ijnes-2016-0024/ijnes-2016-0024.xml. [DOI: 10.1515/ijnes-2016-0024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 10/19/2018] [Indexed: 11/15/2022]
Abstract
AbstractClinical reasoning is the cognitive process that nurses use to gather and incorporate information into a larger bank of personal knowledge. This incorporated information guides therapeutic actions, and helps determine client care. Since the process guides therapeutic actions regarding client care, failure to use the process effectively leads to poor clinical decision-making, inappropriate actions, or inaction. Because of the criticality of this process, this paper presents an analysis of the literature that reveals the current state of the science of clinical reasoning, identifies gaps in knowledge, and elucidates areas for future research. A systematic review of the databases the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Educational Resources Information Center (ERIC), PsychInfo, the Education Full Text (H.W. Wilson), and PubMed revealed 873 articles on the topic of clinical reasoning. Quality appraisal narrowed the field to 27 pieces of literature. Appendix A gives the State of the Science Coding Sheet used to identify the selections used in this research. Appendix B contains a summary of this literature. Although analysis of this literature shows that three theories exist on how to utilize most effectively the clinical reasoning process presently; a clear consistent definition is lacking. Additional research should focus on closing gaps that exist in defining the process, understanding the process, establishing linkages to non-clinical reasoning processes, and developing measures to both develop and accurately measure clinical reasoning.
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Affiliation(s)
- Amy Golden Holder
- East Tennessee State University, Nursing, P.O. Box 70551, Johnson City, TN, USA
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Spence K, Sinclair L, Morritt ML, Laing S. Knowledge and learning in speciality practice. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.jnn.2016.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Simmons B, Lanuza D, Fonteyn M, Hicks F, Holm K. Clinical Reasoning in Experienced Nurses. West J Nurs Res 2016; 25:701-19; discussion 720-4. [PMID: 14528618 DOI: 10.1177/0193945903253092] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
As an essential component of nursing practice, clinical reasoning is used to assimilate information, analyze data, and make decisions regarding patient care. Little is known about the reasoning strategies of experienced nurses who are not yet experts. This qualitative descriptive study explored the cognitive strategies used by experienced nurses as they considered assessment findings of assigned patients. To date, few studies of nurses' clinical reasoning have been conducted in a practice setting during actual patient care. A small group research design was employed using the think-aloud (TA) method with protocol analysis. A total of 15 experienced nurses were asked to “think aloud” about patient assessment findings. Data were audiotaped, transcribed, and analyzed using the three steps of protocol analysis. The results suggest that experienced nurses used a conceptual language to reason about assessment findings and used heuristics to reason more quickly and efficiently.
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Affiliation(s)
- Barbara Simmons
- College of Nursing, Department of Medical-Surgical Nursing, University of Illlinois at Chicago, USA
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Johnsen HM, Slettebø Å, Fossum M. Registered nurses' clinical reasoning in home healthcare clinical practice: A think-aloud study with protocol analysis. NURSE EDUCATION TODAY 2016; 40:95-100. [PMID: 27125156 DOI: 10.1016/j.nedt.2016.02.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 02/02/2016] [Accepted: 02/19/2016] [Indexed: 06/05/2023]
Abstract
BACKGROUND The home healthcare context can be unpredictable and complex, and requires registered nurses with a high level of clinical reasoning skills and professional autonomy. Thus, additional knowledge about registered nurses' clinical reasoning performance during patient home care is required. OBJECTIVES The aim of this study is to describe the cognitive processes and thinking strategies used by recently graduated registered nurses while caring for patients in home healthcare clinical practice. DESIGN An exploratory qualitative think-aloud design with protocol analysis was used. SETTINGS Home healthcare visits to patients with stroke, diabetes, and chronic obstructive pulmonary disease in seven healthcare districts in southern Norway. PARTICIPANTS A purposeful sample of eight registered nurses with one year of experience. METHODS Each nurse was interviewed using the concurrent think-aloud technique in three different patient home healthcare clinical practice visits. A total of 24 home healthcare visits occurred. Follow-up interviews were conducted with each participant. The think-aloud sessions were transcribed and analysed using three-step protocol analysis. RESULTS Recently graduated registered nurses focused on both general nursing concepts and concepts specific to the domains required and tasks provided in home healthcare services as well as for different patient groups. Additionally, participants used several assertion types, cognitive processes, and thinking strategies. CONCLUSIONS Our results showed that recently graduated registered nurses used both simple and complex cognitive processes involving both inductive and deductive reasoning. However, their reasoning was more reactive than proactive. The results may contribute to nursing practice in terms of developing effective nursing education programmes.
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Affiliation(s)
- Hege Mari Johnsen
- Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, Grimstad, Norway.
| | - Åshild Slettebø
- Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, Grimstad, Norway
| | - Mariann Fossum
- Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, Grimstad, Norway
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Regan M, McElroy K. Women’s Perceptions of Childbirth Risk and Place of Birth. THE JOURNAL OF CLINICAL ETHICS 2013. [DOI: 10.1086/jce201324308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Dickson GL, Flynn L. Nurses' clinical reasoning: processes and practices of medication safety. QUALITATIVE HEALTH RESEARCH 2012; 22:3-16. [PMID: 21873283 DOI: 10.1177/1049732311420448] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In this article, we describe the depth of knowledge and skill nurses used in making decisions regarding the safe processes and practices of medication administration. Using grounded theory, we identified the essence of medication safety by nurses as the theme of clinical reasoning. Nurses used two medication safety processes within the clinical reasoning theme-maintaining medication safety and managing the environment-together with six categories of patient-focused medication safety practices in the first process and four categories of environmental-focused safety practices within the second process. These processes and practices present an emerging model of safe medication administration developed from the narratives of 50 medical-surgical nurses. This model provides researchers with the basis for the development of systemic policies for safer medication administration for patients. Health care professional educators might also find the results useful in developing curricula focused on patient safety as the foundation of quality care.
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Affiliation(s)
- Geri L Dickson
- Rutgers, the State University of New Jersey, Newark, College of Nursing, New Jersey07102, USA.
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Deschênes MF, Charlin B, Gagnon R, Goudreau J. Use of a Script Concordance Test to Assess Development of Clinical Reasoning in Nursing Students. J Nurs Educ 2011; 50:381-7. [DOI: 10.3928/01484834-20110331-03] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 08/31/2010] [Indexed: 11/20/2022]
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Lundgrén-Laine H, Salanterä S. Think-aloud technique and protocol analysis in clinical decision-making research. QUALITATIVE HEALTH RESEARCH 2010; 20:565-75. [PMID: 19959822 DOI: 10.1177/1049732309354278] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
In this article, we aim to describe the practical aspects of research actions that should be taken into account when two methods--the think-aloud technique for data collection and protocol analysis as an analysis technique--are combined with research of decision making in acute clinical settings. These methods are rarely used together or written about in health care research. In addition, careful consideration of the pros and cons of study sampling, data collection, data management, and analysis techniques or approaches is still lacking when these methods are used in health care research. We discuss the background of the think-aloud technique and protocol analysis and review previous studies that have used these methods. The examples in the article are based on our study, in which we investigated the decision making of critical care experts. We find that the combination of the think-aloud technique and protocol analysis is applicable when investigating complex and overlapping decision-making processes and rapid, ad hoc decisions made by critical care experts.
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Whyte J, Cormier E, Pickett-Hauber R. Cognitions associated with nurse performance: A comparison of concurrent and retrospective verbal reports of nurse performance in a simulated task environment. Int J Nurs Stud 2010; 47:446-51. [DOI: 10.1016/j.ijnurstu.2009.09.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 08/28/2009] [Accepted: 09/04/2009] [Indexed: 11/27/2022]
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Forneris SG, Peden-McAlpine C. Creating context for critical thinking in practice: the role of the preceptor. J Adv Nurs 2009; 65:1715-24. [DOI: 10.1111/j.1365-2648.2009.05031.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dowding D. Commentary on Banning M (2008) A review of clinical decision making: models and current research. Journal of Clinical Nursing 17, 187-195. J Clin Nurs 2009; 18:309-11. [PMID: 19120761 DOI: 10.1111/j.1365-2702.2008.02471.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Dawn Dowding
- Department of Health Sciences and Hull York Medical School, The University of York, York, UK.
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Han KJ, Kim HS, Kim MJ, Hong KJ, Park S, Yun SN, Song M, Jung Y, Kim H, Kim DOD, Choi H, Kim K. Thinking in clinical nursing practice: a study of critical care nurses' thinking applying the think-aloud, protocol analysis method. Asian Nurs Res (Korean Soc Nurs Sci) 2008; 1:68-82. [PMID: 25030545 DOI: 10.1016/s1976-1317(08)60010-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
PURPOSE The purpose of the paper is to discover the patterns and processes of decision-making in clinical nursing practice. METHODS A set of think-aloud data from five critical care nurses during 40 to 50 minutes of caregiving in intensive care units were obtained and analyzed by applying the procedures recommended by Ericsson and Simon for protocol analysis. RESULTS Four thinking processes before acting were identified to constitute various sorts of thoughts in which the nurses were engaged during patient care: reviewing, validation, consideration, rationalization, and action. In addition, three patterns of sequential streaming of thinking (short, intermediate, long) were identified to reveal various ways the nurses dealt with clinical situations involving nursing tasks and responsibilities. CONCLUSION This study specifies the initial categories of thoughts for each of the processes and various patterns with which these processes are sequentially combined, providing insights into the ways nurses think about problems and address their concerns. The findings suggest that the thinking in clinical practice involves more than focused decision-making and reasoning, and needs to be examined from a broader perspective.
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Affiliation(s)
- Kyung-Ja Han
- Professor, College of Nursing, Seoul National University, Seoul, Korea
| | - Hesook Suzie Kim
- Professor, College of Nursing, University of Rhode Island, Kingston, RI, USA
| | - Mae-Ja Kim
- Professor, College of Nursing, Seoul National University, Seoul, Korea
| | - Kyung-Ja Hong
- Professor, College of Nursing, Seoul National University, Seoul, Korea
| | - Sungae Park
- Professor, College of Nursing, Seoul National University, Seoul, Korea
| | - Soon-Nyoung Yun
- Professor, College of Nursing, Seoul National University, Seoul, Korea
| | - Misoon Song
- Professor, College of Nursing, Seoul National University, Seoul, Korea
| | - Yoenyi Jung
- Department of Nursing, Samsung Medical Center, Seoul, Korea
| | - Haewon Kim
- Professor, Department of Nursing, College of Medicine, Kwandong University, Gangreung, Gangwon do, Korea
| | - Dong-Oak Debbie Kim
- Associate Professor, Department of Nursing, College of Oriental Medicine, Daejeon University, Daejeon, Korea
| | - Heejung Choi
- Associate Professor, Department of Nursing, College of Medicine, Konkuk University, Chungju, Chungbuk, Korea
| | - Kyungae Kim
- Professor, College of Nursing, Seoul National University, Seoul, Korea
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Hunter CL, Spence K, McKenna K, Iedema R. Learning how we learn: an ethnographic study in a neonatal intensive care unit. J Adv Nurs 2008; 62:657-64. [DOI: 10.1111/j.1365-2648.2008.04632.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Banning M. The think aloud approach as an educational tool to develop and assess clinical reasoning in undergraduate students. NURSE EDUCATION TODAY 2008; 28:8-14. [PMID: 17383056 DOI: 10.1016/j.nedt.2007.02.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2006] [Revised: 01/17/2007] [Accepted: 02/04/2007] [Indexed: 05/14/2023]
Abstract
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.
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Affiliation(s)
- Maggi Banning
- Brunel University, School of Health Studies and Social Care, Mary Seacole Building, Uxbridge UB8 3PH, Middlesex, United Kingdom.
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Twycross A. What is the impact of theoretical knowledge on children's nurses' post-operative pain management practices? An exploratory study. NURSE EDUCATION TODAY 2007; 27:697-707. [PMID: 17134793 DOI: 10.1016/j.nedt.2006.10.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2006] [Revised: 08/22/2006] [Accepted: 10/10/2006] [Indexed: 05/12/2023]
Abstract
Despite the availability of the evidence to guide pain management practices, practices are often sub-optimal with children experiencing moderate to severe pain post-operatively. Limited theoretical knowledge about managing pain has been suggested as one reason for this. Several studies have identified gaps in nurses' theoretical knowledge. However, the affect of theoretical knowledge on pain management practices has not been explored. This explored whether there is a relationship between nurses' theoretical knowledge and the quality of their practices. Nurses (n=13) on one children's surgical ward were shadowed for a five-hour period during two-four shifts. Data about post-operative pain management practices were collected using a pain management checklist and field notes. Nurses (n=12) also completed the revised pain management knowledge test. Questionnaire scores were compared to the observational data. No positive relationship was found between nurses' level of theoretical knowledge and how well they actually managed pain. Nurses did not appear to routinely apply theoretical knowledge in practice. This may explain, at least in part, why pain management practices remain poor despite the evidence to guide practice being readily available. The hypothesis, put forward in other studies, that increasing nurses' theoretical knowledge about pain will improve practices may be overly simplistic.
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Affiliation(s)
- Alison Twycross
- Faculty of Health and Social Care Sciences, Kingston University, St George's University of London, Grosvenor Wing, St George's Hospital, London, UK.
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Banning M. Clinical reasoning and its application to nursing: concepts and research studies. Nurse Educ Pract 2007; 8:177-83. [PMID: 17869587 DOI: 10.1016/j.nepr.2007.06.004] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Revised: 02/01/2007] [Accepted: 06/07/2007] [Indexed: 10/22/2022]
Abstract
Clinical reasoning may be defined as "the process of applying knowledge and expertise to a clinical situation to develop a solution" [Carr, S., 2004. A framework for understanding clinical reasoning in community nursing. J. Clin. Nursing 13 (7), 850-857]. Several forms of reasoning exist each has its own merits and uses. Reasoning involves the processes of cognition or thinking and metacognition. In nursing, clinical reasoning skills are an expected component of expert and competent practise. Nurse research studies have identified concepts, processes and thinking strategies that might underpin the clinical reasoning used by pre-registration nurses and experienced nurses. Much of the available research on reasoning is based on the use of the think aloud approach. Although this is a useful method, it is dependent on ability to describe and verbalise the reasoning process. More nursing research is needed to explore the clinical reasoning process. Investment in teaching and learning methods is needed to enhance clinical reasoning skills in nurses.
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Affiliation(s)
- Maggi Banning
- Brunel University, School of Health Sciences and Social Care, Mary Seacole Building, Uxbridge UB8 3PH, Middlesex, United Kingdom.
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Funkesson KH, Anbäcken EM, Ek AC. Nurses’ reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study. Int J Nurs Stud 2007; 44:1109-19. [PMID: 16806220 DOI: 10.1016/j.ijnurstu.2006.04.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Revised: 02/21/2006] [Accepted: 04/27/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND Nurses' clinical reasoning is of great importance for the delivery of safe and efficient care. Pressure ulcer prevention allows a variety of aspects within nursing to be viewed. OBJECTIVE The aim of this study was to describe both the process and the content of nurses' reasoning during care planning at different nursing homes, using pressure ulcer prevention as an example. DESIGN A qualitative research design was chosen. SETTINGS Seven different nursing homes within one community were included. PARTICIPANTS Eleven registered nurses were interviewed. METHOD The methods used were think-aloud technique, protocol analysis and qualitative content analysis. Client simulation illustrating transition was used. The case used for care planning was in three parts covering the transition from hospital until 3 weeks in the nursing home. RESULT Most nurses in this study conducted direct and indirect reasoning in a wide range of areas in connection with pressure ulcer prevention. The reasoning focused different parts of the nursing process depending on part of the case. Complex assertations as well as strategies aiming to reduce cognitive strain were rare. Nurses involved in direct nursing care held a broader reasoning than consultant nurses. Both explanations and actions based on older ideas and traditions occurred. CONCLUSIONS Reasoning concerning pressure ulcer prevention while care planning was dominated by routine thinking. Knowing the person over a period of time made a more complex reasoning possible. The nurses' experience, knowledge together with how close to the elderly the nurses work seem to be important factors that affect the content of reasoning.
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Measuring nursing unit culture as an empirical basis for implementing a model of practice in a neonatal intensive care unit. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.jnn.2005.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Tiwari A, Avery A, Lai P. Critical thinking disposition of Hong Kong Chinese and Australian nursing students. J Adv Nurs 2004; 44:298-307. [PMID: 14641400 DOI: 10.1046/j.1365-2648.2003.02805.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Critical thinking is frequently cited as a desirable professional attribute and a highly valued educational outcome. Despite the abundance of literature on the subject, validation of the critical thinking construct in different cultural populations is under-researched. AIM The purpose of this study was to compare the critical thinking dispositions of Hong Kong Chinese and Australian nursing students. DESIGN A cross-sectional design was used with two groups of nursing students in two universities, one in Hong Kong and the other in Australia. Critical thinking disposition was measured using the California Critical Thinking Disposition Inventory (CCTDI). RESULTS Significant differences were detected in critical thinking disposition between the two groups of students (P < 0.05), with the Hong Kong Chinese students failing to show a positive disposition toward critical thinking on the CCTDI total mean score, while the Australian students showed a positive disposition. Similarities and differences were also noted between the groups in CCTDI subscale mean scores. CONCLUSION The findings contribute to knowledge of critical thinking by demonstrating differences and similarities between Hong Kong Chinese and Australian nursing students. The study raises questions about the effects of institutional, educational, professional and cultural factors on the disposition to think critically.
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Affiliation(s)
- Agnes Tiwari
- Department of Nursing Studies, The University of Hong Kong, Hong Kong.
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Irby DM, Aagaard E, Teherani A. Teaching points identified by preceptors observing one-minute preceptor and traditional preceptor encounters. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2004; 79:50-55. [PMID: 14690997 DOI: 10.1097/00001888-200401000-00012] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
PURPOSE This study examined the teaching points made by preceptors in response to two videotaped teaching encounters to determine if (1) different preceptors use similar teaching points in response to the same case, (2) preceptors' teaching points vary by case, and (3) preceptors' teaching points vary by teaching model (One-Minute Preceptor and traditional preceptor models). METHOD Preceptors (n = 116) at seven universities participated in a within-groups experimental design study in 2000. The preceptors viewed videotaped encounters depicting two cases and two precepting models. They were asked to list two teaching points after viewing the initial case presentations and after the teaching encounters were completed. Frequency of teaching points listed by preceptors was examined for each case and teaching model. Teaching points were coded using qualitative methods and then analyzed using repeated-measures analysis of variance. RESULTS Of the 843 total teaching points identified by preceptors, 63 were discrete teaching points that were aggregated into 15 categories. Most preceptors (82%) listed three to five separate teaching points, which varied significantly by case and model. Those observing the traditional precepting model were more likely to teach generic skills such as history-taking skills, presentation skills, and risk factors, and those observing the One-Minute Preceptor were more likely to teach about the illness focusing on a broader differential diagnosis, further diagnostic tests, and the natural presentation of disease. CONCLUSIONS Preceptors use three to five common teaching points that vary by case and teaching model. The One-Minute Preceptor model shifted teaching points away from generic clinical skills toward disease-specific teaching.
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Affiliation(s)
- David M Irby
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco 94143-0410, USA.
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Ewing G, Freer Y, Logie R, Hunter J, McIntosh N, Rudkin S, Ferguson L. Role and experience determine decision support interface requirements in a neonatal intensive care environment. J Biomed Inform 2003; 36:240-9. [PMID: 14643719 DOI: 10.1016/j.jbi.2003.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this paper is to describe a novel approach to the analysis of data obtained from card-sorting experiments. These experiments were performed as a part of the initial phase of a project, called NEONATE. One of the aims of the project is to develop decision support tools for the neonatal intensive care environment. Physical card-sorts were performed using clinical "action" and patient "descriptor" words. Thirty-two staff (eight junior nurses, eight senior nurses, eight junior doctors, and eight senior doctors) participated in the actions card-sorts and the same number of staff participated in separate descriptors card-sorting experiments. To check for consistency, the card-sorts were replicated for nurses during the action card-sorts. The card-sort data were analysed using hierarchical cluster analysis to produce tree-diagrams or dendrograms. Differences were shown in the way various classes of staff with different levels of experience mentally map clinical concepts. Clinical actions were grouped more loosely by nurses and by those with less experience, with a polarisation between senior doctors and junior nurses. Descriptors were classed more definitively and similarly by nurses and senior doctors but in a less structured way and quite differently by junior doctors. This paper presents a summary of the differences in the card-sort data for the various staff categories. It is shown that concepts are used differently by various staff groups in a neonatal unit and that this may diminish the effectiveness of computerised decision aids unless it is explored during their development.
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Affiliation(s)
- Gary Ewing
- Department of Computing Science, King's College, University of Aberdeen, Aberdeen, UK.
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McCarthy M. Situated clinical reasoning: distinguishing acute confusion from dementia in hospitalized older adults. Res Nurs Health 2003; 26:90-101. [PMID: 12652606 DOI: 10.1002/nur.10079] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In this study a dimensional analysis approach was used to explore the clinical reasoning of nurses who care for hospitalized older adults to identify factors that might explain their failure to detect acute confusion and to distinguish it from dementia in this patient population. Data analysis yielded a grounded theory of situated clinical reasoning, which proposes that the ability of nurses to identify acute confusion varies widely. This variation can be attributed to the differences in nurses' philosophical perspectives on aging. According to this theory, three distinct perspectives are unwittingly embraced by nurses who care for older patients. These perspectives influence how nurses characterize aging and the aged and condition the ways in which they judge and ultimately deal with older adults in clinical situations.
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Affiliation(s)
- Marianne McCarthy
- Arizona State University, College of Nursing, Main Campus, P.O. Box 872602, Tempe, AZ 85287-2602, USA
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Gosling AS, Westbrook JI, Coiera EW. Variation in the use of online clinical evidence: a qualitative analysis. Int J Med Inform 2003; 69:1-16. [PMID: 12485700 DOI: 10.1016/s1386-5056(02)00046-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To investigate factors influencing variations in clinicians' use of an online evidence retrieval system. SETTING Public hospitals in New South Wales, Australia. METHOD Web log analysis demonstrated considerable variation in rates of evidence use by clinicians at different hospitals. Focus groups and interviews were held with 61 staff from three hospitals, two with high rates of use and one with a low rate of use, to explore variation in evidence use. RESULTS Differences between hospitals' and professional groups' (doctors, nurses and allied health) use of online evidence could be explained by organizational, professional and cultural factors. These included the presence of champions, organizational cultures which supported evidence-based practice (EBP), and database searching skills of individual clinicians. Staff shortages, ease of access and time taken to use the online evidence system were cited as barriers to use at the low use site, but no objective differences in these measures were found between the high and low use sites. CONCLUSION Social and cultural factors were found to be better discriminators of high and low evidence use than technical factors.
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Affiliation(s)
- A Sophie Gosling
- Center for Health Informatics, Level 2, Samuels Building, University of New South Wales, Sydney 2052, Australia.
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