Facilitating Clinical Reasoning in the Skills Laboratory:Reasoning Model Versus Nursing Process-Based Skills Checklist

Abstract

The need for nursing education to shift from an em- phasis on critical to an emphasis on clini- cal reasoning and multiple ways of that include critical thinking has been well documented (Benner, Sut- phen, Leonard, & Day, 2010, p. 84). The application of effective reasoning is especially important when teaching psychomotor skills. Traditional approaches to skills acqui- sition that focused on nursing-process-based skills check- lists have emphasized content retention without ensuring that understanding and reasoning are taking place (Baxter & Boblin, 2008).The ability of the student to perform psychomotor skills without understanding the associated reasoning is often revealed when the student is questioned about a skill during a return demonstration or in the clinical set- ting and cannot provide a rationale for a skill. The neces- sity for teaching clinical reasoning during the application of nursing skills is underscored by the need to provide safe and appropriate care in an increasingly complex health care environment.Much has been written about developing reasoning in the clinical and classroom setting, yet few studies have used the clinical skills laboratory as a testing ground. In an editorial, Tanner asked, Where and how will students learn to connect the evidence they have found and ap- praised to their clinical reasoning and the many judgments they make in practice? (2008, p. 335). Nestel, Groom, Eikeland-Husebo, and O'Donnell (2011) completed a sys- tematic review of studies investigating the use of simula- tion for teaching procedural skills. The emphasis in these studies was on skills acquisition, knowledge, attitude, and learner satisfaction. The authors noted the need for instructional design and educational theory to be consid- ered in simulation programs and identified the need for more high quality research designs. Lapkin, Levett-Jones, Bellchambers, and Fernandez (2010), in a systematic re- view on the usefulness of simulation manikins to teach reasoning, found only two studies that focused on the ef- fectiveness of simulation to assess and evaluate clinical skills performance; neither study integrated the use of a reasoning model when teaching skills.There is a need to investigate the effectiveness of cur- rent teaching methodologies used to enhance reasoning in students. Lasater's (2007) clinical judgment rubric, based on Tanner's clinical judgment model (2006), was tested in the clinical simulation area in an effort to provide students with insight into their clinical judgment performance. Webber's IRUEPIC reasoning model, introduced in 2000 and revised in 2010 (Johnson & Webber, 2010), contains seven steps that build progressively, resulting in actions based on effective reasoning: Identify, Relate, Understand, Explain, Predict, Influence, and Control (IRUEPIC). The model seeks to develop effective reasoning by showing stu- dents how assessment data can be put into relationships that, in turn, guide understanding of the relationships and result in appropriate interventions.When using a teaching method that incorporates the scientific rationale behind the skill, the why becomes integral to the specific skill, and the skill is seen as part of an entire process that now has meaning. The purpose of this study was to determine if application of the IRUE- PIC reasoning model when teaching psychomotor skills was more effective than the nursing-process-based skills checklist method in facilitating student reasoning as mea- sured by intellectual performance in the campus learning laboratory. Intellectual performance was defined as the application of the reasoning process to the performance of psychomotor nursing skills.MethodThe university's institutional review board exempted the study. Using a quasi-experimental approach, two sections of the campus skills lab were taught using the traditional nursing-process-based skills checklist (n = 14), and two were taught using the IRUEPIC reasoning model (n = 16). …