The think aloud approach as an educational tool to develop and assess clinical reasoning in undergraduate studentsIntroductionMeasures used to teach pre-registration nursing studentsThe think aloud approachConclusionsReferencesThe think aloud approach as an educational tool todevelop and assess clinical reasoning inundergraduate studentsMaggi Banning*Brunel University, School of Health Studies and Social Care, Mary Seacole Building, Uxbridge UB8 3PH,Middlesex, United KingdomAccepted 4 February 2007KEYWORDSClinical reasoning;Think aloud seminar;Process orientedmethods;Nurse educationSummary Even though clinical reasoning is attributed with the expert practitioner,there is limited evidence to support methods of teaching and learning that are usedto foster its development in nurses. In nursing, a considerable range of teaching andlearning strategies are available that can be used to develop clinical reasoning skills.This includes the think aloud seminar. This process oriented method has been suc-cessfully 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 casestudy of a child with pharyngitis. J. Pediatric Health Care 11(1), 105–110.] and isone that should be adopted by nurse educators as a core teaching and learning strat-egy when educating pre-registration student nurses.c2007 Elsevier Ltd. All rights reserved.IntroductionClinical reasoning is an essential feature of healthcare practice that focuses on the assimilation,analysis and differentiation of health care evi-dence. This evidence is then applied to selectivegroups of patients and decisions are made perti-nent to their nursing management (Fonteynet al., 1993, Simmons et al., 2003). Clinical reason-ing may be defined as ‘‘an inferential process usedby practitioners to collect and evaluate data and tomake judgments about the diagnosis and manage-ment of patient problems’’ (Lee and Ryan-Wenger,1997, p. 101). This process is iterative and recur-sive and a central feature of self-regulated learn-ing. It is proposed that clinical reasoning is acognitive process which involves both metacogni-tion (reflective thinking) and cognition (thinking);both are inextricably linked and essential compo-nents of the reasoning process (Kuiper, 2003, Kui-per and Pesut, 2004).Metacognition is a term used in educational psy-chology which refers to higher order thinking and0260-6917/$ - see front matterc2007 Elsevier Ltd. All rights reserved.doi:10.1016/j.nedt.2007.02.001*Tel.: +44 01895 68819.E-mail address: [email protected] Education Today (2008) 28, 8–14intl.elsevierhealth.com/journals/nedtNurseEducationTodayinvolves the active control of cognitive (thinking)processes and the assessment of to what extentcognitive outcomes have been achieved in relationto learning situations (Flavell, 1987, Wikipedia,2006). Learning situations may involve planning,monitoring, and evaluating a given task. In generalterms, metacognition can be thought of as ‘‘think-ing about thinking’’ as it consists of metacognitiveregulation or strategies that are used to control oroversee cognitive activities and goals and metacog-nitive knowledge which may be factual, explicit orimplicit (Wikipedia, 2006). Knowledge may be gen-eralised according to personal variables, task orstrategic variables (Flavell, 1987). Metacognitiveprocessing will then use these forms of knowledgeto participate in cognitive activities to ensure cog-nitive goals and outcomes are met (Brown, 1987).During this process individuals will use bothinductive and deductive logic to simultaneouslyassemble and evaluate patient information andsupportive evidence before making judgementsabout nursing care (Higgs et al., 2001, Simmonset al., 2003).The importance of clinical reasoning to nursingpractice cannot be underestimated (Simmonset al., 2003). It is proposed that clinical reason-ing is an innate feature of nursing that impactson the provision of carefully planned and exe-cuted nursing care (Burns and Higgs, 2000) andis a process that nurses at all levels engage inFisher and Fonteyn (1995). However, some viewclinical reasoning as the hallmark of the nursingexpert (Fowler, 1997) which can be used to dis-tinguish the expert from the novice nurse(Junnola et al., 2002). Clinical reasoning is com-posed of several subcomponents; intuition, do-main-specific knowledge and experience (Bennerand Tanner, 1997, Crow et al., 1995, Parkeret al., 1999). Each of these components can beused to enhance the quality of care providedto patients using a process that involves ‘‘apply-ing knowledge and expertise to a clinicalsituation to develop a solution’’ (Carr, 2004, p.851).Although numerous nursing research studieshave explored the concept of clinical reasoning(Fowler, 1997, Bucknall, 2003, Kuiper, 2003, Kuiperand Pesut, 2004, Carr, 2004) there is no consensuson the definition, characteristics or subcomponentsor the methods that should be employed by nurseeducators to teach clinical reasoning to pre-regis-tration nursing students. The aim of this paper isto examine the use of the think aloud approachas an exemplar of a teaching and learning strategythat can be employed to develop nurses’ ability toclinically reason.Measures used to teach pre-registrationnursing studentsThe earliest methods of teaching clinical nursingrevolved around the apprenticeship scheme thatinvolved the see one, do one, teach one ap-proach. This time-aged strategy for teachingnurses failed to provide any supporting rationalefor the choice of nursing management selectedfor patients and concentrated in viewing patientsas a homogenous group dependent on their patho-physiological complaint. Nurses in training gener-ally were not taught to think critically about thecare that could be provided for the patient. How-ever, as the nurse gained professional nursingexperience they learned to consider the patientand their psychological, physical needs and nurs-ing care requirements. This time aged approachto patient care was fostered by didactic ap-proaches to teaching and learning.Didactic approaches to nurse education such asthe lecture have been used for decades to teachclinical theory, and the art and scientific basis ofnursing. This approach continues to be ‘‘the mostfrequently employed teaching technique’’ (Jarvis,1983, p. 117), as it is an economical way of trans-mitting new theoretical