Development and evaluation of a structured learning strategy to improve clinical reasoning of nursing students

Abstract

Healthcare services have become highly challenging and diverse, with the nursing shortage, increasing social demand and technology advancement necessitating nurses to possess clinical-reasoning skills to deliver high-quality patient care. Evidence suggests that medical errors result commonly from clinical-reasoning incompetence. Nursing students often exhibit a lower level of clinical-reasoning ability, leading to reduced confidence and compromised decision-making skills during clinical practice. This deficiency in clinical reasoning has been linked to unsafe practices. Conventional teaching strategies lack the ability to effectively enhance clinical reasoning since they fail to actively engage students in constructing knowledge by connecting existing understanding to new insights. Mind mapping has proven to be a potential tool in promoting clinical reasoning, however, students often face challenges in identifying relationships within collected data when lacking guidance. Incorporated a “framework” into mind mapping provides direction holds great potential for enhancing clinical reasoning. Hence, the objective of this study is to develop a mind map integrated with an instructional approach of framework specifically designed for use in a tertiary education setting. This approach has the potential to elevate overall clinical performance by improving clinical-reasoning skills, boosting self-confidence and lowering anxiety levels, and enhancing clinical decision-making processes. The key objectives of this study are to assess the impact of the mind mapping with explicit structure on nursing students’ 1) self-perceived clinical-reasoning ability, 2) self-confidence level, 3) anxiety level and 4) clinical decision-making ability. This study employed a quasiexperimental pretest-posttest design with a quantitative approach and was conducted at the School of Nursing of a local tertiary institute in Hong Kong. Purposive sampling was conducted, and the study sample consisted of a total of 125 nursing students. The intervention group (n = 67) attended a 2-hour case study tutorial session for the new structured learning strategy, that is, the PHsHIT mind map, whereas the control group (n = 58) attended a standard teaching session. The participants completed a demographic questionnaire and quantitative instruments for assessing their self-perceived clinical-reasoning ability, self-confidence and anxiety levels and clinical decision-making ability. Data analysis was performed by using SPSS version 26 and the generalised estimating equations (GEE) method. The data were collected at three time points: (a) pretraining, (b) posttraining and (c) postintervention, after the students completed their clinical practicum. Results indicated that the intervention and control groups exhibited improvements in their self-perceived clinical-reasoning ability and self-confidence and anxiety levels. However, the intervention effect was not superior to the control effect. Notably, at the posttraining time point, a significant difference was observed between the two groups in terms of their clinical decision-making ability (MD = 1.18, SE = 0.35, p = 0.001), which suggested that the structured learning strategy had a short-term training effect on clinical decision-making ability. The nursing students provided encouraging feedback on their usage (80.35%) of the new learning strategy and satisfaction (70.59%) with its performance in enhancing their clinical reasoning. In conclusion, the findings of this study indicate that the implementation of the structured learning strategy was not effective for improving nursing students’ clinical-reasoning ability compared to standard teaching strategy. However, the structured learning strategy using a mind map exhibited short-term benefits for improving students’ clinical decision-making ability. Further exploration and refinement of this strategy including the intervention duration and frequency, and application in clinical learning may unveil its full potential in enhancing clinical reasoning abilities over extended periods of training and practice.