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Nurse Education Today 2008 28 8 14 Nurse Education Today intl elsevierhealth com journals nedt The think aloud approach as an educational tool to develop and assess clinical reasoning in undergraduate students Maggi Banning Brunel University School of Health Studies and Social Care Mary Seacole Building Uxbridge UB8 3PH Middlesex United Kingdom Accepted 4 February 2007 KEYWORDS Summary 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 RyanWenger 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 c 2007 Elsevier Ltd All rights reserved Clinical reasoning Think aloud seminar Process oriented methods Nurse education Introduction Clinical reasoning is an essential feature of health care practice that focuses on the assimilation analysis and differentiation of health care evidence This evidence is then applied to selective groups of patients and decisions are made pertinent to their nursing management Fonteyn et al 1993 Simmons et al 2003 Clinical reasoning may be defined as an inferential process used Tel 44 01895 68819 E mail address maggi banning brunel ac uk by practitioners to collect and evaluate data and to make judgments about the diagnosis and management of patient problems Lee and Ryan Wenger 1997 p 101 This process is iterative and recursive and a central feature of self regulated learning It is proposed that clinical reasoning is a cognitive process which involves both metacognition reflective thinking and cognition thinking both are inextricably linked and essential components of the reasoning process Kuiper 2003 Kuiper and Pesut 2004 Metacognition is a term used in educational psychology which refers to higher order thinking and 0260 6917 see front matter c 2007 Elsevier Ltd All rights reserved doi 10 1016 j nedt 2007 02 001 The think aloud approach as an educational tool to develop and assess clinical reasoning involves the active control of cognitive thinking processes and the assessment of to what extent cognitive outcomes have been achieved in relation to learning situations Flavell 1987 Wikipedia 2006 Learning situations may involve planning monitoring and evaluating a given task In general terms metacognition can be thought of as thinking about thinking as it consists of metacognitive regulation or strategies that are used to control or oversee cognitive activities and goals and metacognitive knowledge which may be factual explicit or implicit Wikipedia 2006 Knowledge may be generalised according to personal variables task or strategic variables Flavell 1987 Metacognitive processing will then use these forms of knowledge to participate in cognitive activities to ensure cognitive goals and outcomes are met Brown 1987 During this process individuals will use both inductive and deductive logic to simultaneously assemble and evaluate patient information and supportive evidence before making judgements about nursing care Higgs et al 2001 Simmons et al 2003 The importance of clinical reasoning to nursing practice cannot be underestimated Simmons et al 2003 It is proposed that clinical reasoning is an innate feature of nursing that impacts on the provision of carefully planned and executed nursing care Burns and Higgs 2000 and is a process that nurses at all levels engage in Fisher and Fonteyn 1995 However some view clinical reasoning as the hallmark of the nursing expert Fowler 1997 which can be used to distinguish the expert from the novice nurse Junnola et al 2002 Clinical reasoning is composed of several subcomponents intuition domain specific knowledge and experience Benner and Tanner 1997 Crow et al 1995 Parker et al 1999 Each of these components can be used to enhance the quality of care provided to patients using a process that involves applying knowledge and expertise to a clinical situation to develop a solution Carr 2004 p 851 Although numerous nursing research studies have explored the concept of clinical reasoning Fowler 1997 Bucknall 2003 Kuiper 2003 Kuiper and Pesut 2004 Carr 2004 there is no consensus on the definition characteristics or subcomponents or the methods that should be employed by nurse educators to teach clinical reasoning to pre registration nursing students The aim of this paper is to examine the use of the think aloud approach as an exemplar of a teaching and learning strategy that can be employed to develop nurses ability to clinically reason 9 Measures used to teach pre registration nursing students The earliest methods of teaching clinical nursing revolved around the apprenticeship scheme that involved the see one do one teach one approach This time aged strategy for teaching nurses failed to provide any supporting rationale for the choice of nursing management selected for patients and concentrated in viewing patients as a homogenous group dependent on their pathophysiological complaint Nurses in training generally were not taught to think critically about the care that could be provided for the patient However as the nurse gained professional nursing experience they learned to consider the patient and their psychological physical needs and nursing care requirements This time aged approach to patient care was fostered by didactic approaches to teaching and learning Didactic approaches to nurse education such as the lecture have been used for decades to teach clinical theory and the art and scientific basis of nursing This approach continues to be the most frequently employed teaching technique Jarvis 1983 p 117 as it is an economical way of transmitting new theoretical principles and factual evidence to large audiences Walkin 2000 Although the lecture is recognised as a useful teaching method Fry et al 2003 it can often lead to bored and unstimulated students who learn superficially often using learn using rote learning methods and a reproducing orientation to learning Entwistle

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