Strategies for closing the education-to-practice gap in nursing

Q. For years there was an emphasis on developing nursing students’ critical thinking skills. How is clinical reasoning different?

Excellent question. Critical thinking is one kind of cognitive process nurses use to address complex and ill-defined patient care problems. Interestingly, while critical thinking is a cornerstone of contemporary nursing education there is not an agreed upon definition and some controversy as to whether critical thinking is a skill, a process, or better described as a set of cognitive habits or attributes. Nursing education has been using the term critical thinking for nearly 30 years to describe the cognitive skill and process we should be teaching our students to use, but we have never developed valid instruments to measure it. In the sentinel study Educating Nurses, Benner and associates (2010) reported nursing education has used critical thinking as a catch all phrase for the many kinds of thinking that nurses use in practice. They identified multiple kinds of thinking nurses use to reason and develop solutions. Some of the multiple kinds of thinking nurses use are critical, creative, scientific, and formal. Tanner’s (2006) publication Thinking Like a Nurse also shifted the emphasis from critical thinking to clinical reasoning and judgment. Tanner’s theory is based on over 200 studies addressing nurses’ thinking patterns and identified other important aspects of what it means to think like a nurse (Tanner, 2006). Patricia Benner and Chris Tanner have been researching clinical reasoning and judgment for years and provide us with analysis and narratives we can use to help students learn to think like a nurse.

Q. What has caused the shift to more emphasis on clinical reasoning in the educational environment? Why is this change important?

The kinds of patient care situations nurses encounter in practice require complex reasoning and decision-making. The new science of learning and decision-making science provide new insight into cognitive process nurses use. There is greater emphasis in practice as research shows connection between the ability of nurses to apply sound clinical reasoning and patient care outcomes. Benner, Tanner’s, and other research has been influential in this area. The importance of the nurse’s background, context of the situation, and knowing the patient are also crucial variables leading to the nurse’s ability to identify what is salient in a complex patient care situation. The ability to reason as the clinical situation changes is also crucial for providing safe, quality, and patient-centered care.

Q. In addition to clinical reasoning, we’re also hearing more about clinical judgment. How would you describe the difference between the two?

Clinical reasoning and clinical judgment are integral concepts and often used interchangeably. We defined clinical reasoning as a complex process that uses cognition, metacognition, and discipline-specific knowledge to gather and analyze patient information, evaluate its significance, and weigh alternative actions (Simmons, 2010, p. 1151). Tanner (2006) adds to our understanding and provides an elegant distinction between clinical reasoning and judgment: “Clinical judgment is the outcome of the clinical reasoning process and is defined as …an interpretation or conclusion about a patient’s needs, concerns, or health problems and/or the decision to take action (or not), and to use or modify standard approaches, or to improvise new ones as deemed appropriate by the patient’s response” (Tanner, 2006, p. 204). Benner and associates (2010)

Why are they both important in helping students “think like a nurse”?

Nursing education must address both the thinking (clinical reasoning) and support development of the attributes required to make a decision (clinical judgment) to take action, which is the outcome of clinical reasoning.

Q. What effect will this change in focus have on what’s known as, the education-to-practice gap, and better preparing graduates for the working world?

Today’s practice requires nurses to care for patients and their family with multiple health care problems and illnesses in complex healthcare systems. Nursing care has always required cognitive process and logical reasoning. Patient care issues are more complex and frequently ill-defined. Informatics provides multiple resources for nurses to use in practice and solutions must be evidence-based. Supporting the development of clinical reasoning and judgment will better prepare graduates for providing safe, quality, patient-centered care required in today’s practice environment.

Q. Do you have any suggestions or tips for how to better foster/implement clinical reasoning in nursing education?

Yes! Students need the opportunity to develop the cognitive processes used in clinical reasoning. This requires deep knowledge and understanding of the prevalent patient conditions they will encounter in practice. Case-based teaching, experiential, and active learning with guided reflection are important strategies. The recent literature on flipping the classroom provides guidance on how to facilitate active learning and reflection. High fidelity simulation and concept-based clinical activities are clinical teaching approaches that can be developed as strategies for the educator’s toolkit. Coaching for a sense of salience and expert modeling are other clinical teaching strategies identified as being influential in developing clinical reasoning.

 

About the Author

Paula Gubrud-Howe, Ed.D., RN, FAAN, is currently the Senior Associate Dean for Education at the Oregon Health & Science University School of Nursing in Portland Oregon. She is also part of the author team for Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 6th edition.