Presenting Cues to Promote Clinical Reasoning in Physical Assessment for Undergraduate Nursing Students: A Randomized Controlled Study

A comprehensive pedagogical strategy to cultivate clinical reasoning and problem-solving skills in nursing education.

BackgroundThe illness script method employs a theoretical outline (e.g., epidemiology, pathophysiology, signs and symptoms, diagnostic tests, interventions) to clarify how clinicians organized medical knowledge for clinical reasoning in the diagnosis domain. We hypothesized that an educational intervention based on the illness script method would improve medical students’ clinical reasoning skills in the diagnosis domain.MethodsThis study is a randomized controlled trial involving 100 fourth-year medical students in Shiraz Medical School, Iran. Fifty students were randomized to the intervention group, who were taught clinical reasoning skills based on the illness script method for three diseases during one clinical scenario. Another 50 students were randomized to the control group, who were taught the clinical presentation based on signs and symptoms of the same three diseases as the intervention group. The outcomes of interest were learner satisfaction with the intervention and posttest scores on both an internally developed knowledge test and a Script Concordance Test (SCT).ResultsOf the hundred participating fourth-year medical students, 47 (47%) were male, and 53 (53%) were female. On the knowledge test, there was no difference in pretest scores between the intervention and control group, which suggested a similar baseline knowledge in both groups; however, posttest scores in the intervention group were (15.74 ± 2.47 out of 20) statistically significantly higher than the control group (14.38 ± 2.59 out of 20, P = 0.009). On the SCT, the mean score for the intervention group (6.12 ± 1.95 out of 10) was significantly higher than the control group (4.54 ± 1.56 out of 10; P = 0.0001). Learner satisfaction data indicated that the intervention was well-received by students.ConclusionTeaching with the illness script method was an effective way to improve students’ clinical reasoning skills in the diagnosis domain suggested by posttest and SCT scores for specific clinical scenarios. Whether this approach translates to improved generalized clinical reasoning skills in real clinical settings merits further study.

BackgroundThe human bone anatomy is commonly taught using normal adult bones. However, students often face difficulties comprehending the clinical correlations related to fractures, as they only rely on text content or diagrams without three-dimensional visual aids. Therefore, this study aims to evaluate the effectiveness of using 3D-printed models of limb bone fractures in routine osteology classes to enhance the clinical reasoning skills of first-year medical undergraduate students.MethodologyIn this experimental study, 105 first-year medical undergraduate students were divided into intervention and control groups based on their pre-assigned serial numbers. The control group was taught using dry adult human bones, with the teacher explaining clinical correlations verbally. Meanwhile, in two sessions, the intervention group was taught using 3D-printed models of fractures in addition to real bones. At the end of the second session, students were evaluated for their clinical reasoning ability using a case-based MCQ test (maximum score 5). The scores were compared between the two groups using an unpaired t-test. Students of the intervention group were asked to rate their learning experience using a 10-point Likert Scale questionnaire.ResultsThe intervention group scored significantly higher (2.54 ± 1.15) than the control group (2.04 ± 0.94) (p = 0.015). The maximum score for both groups was five, and the minimum was one. Most students agreed that the 3D-printed models helped them understand the fractures’ clinical relevance and provided better orientation to the bones, joints, and structures involved in fractures (92%, n = 46). The students expressed a desire for more similar types of sessions.ConclusionIncorporating 3D-printed models of fractures was a novel approach to help students comprehend the clinical correlations. This strategy improved students’ clinical reasoning skills in the intervention group, as evidenced by their higher scores and feedback. Therefore, 3D-printed models are a valuable addition to the traditional teaching methods of learning osteology.

Situativity theory posits that learning and the development of clinical reasoning skills are grounded in context. In case-based teaching, this context comes from recreating the clinical environment, through emulation, as with manikins, or description. In this study, we sought to understand the difference in student clinical reasoning abilities after facilitated patient case scenarios with or without a manikin. Fourth-year medical students in an internship readiness course were randomized into patient case scenarios without manikin (control group) and with manikin (intervention group) for a chest pain session. The control and intervention groups had identical student-led case progression and faculty debriefing objectives. Clinical reasoning skills were assessed after the session using a 64-question script concordance test (SCT). The test was developed and piloted prior to administration. Hospitalist and emergency medicine faculty responses on the test items served as the expert standard for scoring. Ninety-six students were randomized to case-based sessions with (n = 48) or without (n = 48) manikin. Ninety students completed the SCT (with manikin n = 45, without manikin n = 45). A statistically significant mean difference on test performance between the two groups was found (t = 3.059, df = 88, p = .003), with the manikin group achieving higher SCT scores. Use of a manikin in simulated patient case discussion significantly improves students' clinical reasoning skills, as measured by SCT. These results suggest that using a manikin to simulate a patient scenario situates learning, thereby enhancing skill development.

This study aims to compare the effectiveness of Hybrid and Pure problem-based learning (PBL) in teaching clinical reasoning skills to medical students. The study sample consisted of 99 medical students participating in a clerkship rotation at the Department of General Medicine, Chiba University Hospital. They were randomly assigned to Hybrid PBL (intervention group, n = 52) or Pure PBL group (control group, n = 47). The quantitative outcomes were measured with the students' perceived competence in PBL, satisfaction with sessions, and self-evaluation of competency in clinical reasoning. The qualitative component consisted of a content analysis on the benefits of learning clinical reasoning using Hybrid PBL. There was no significant difference between intervention and control groups in the five students' perceived competence and satisfaction with sessions. In two-way repeated measure analysis of variance, self-evaluation of competency in clinical reasoning was significantly improved in the intervention group in "recalling appropriate differential diagnosis from patient's chief complaint" (F(1,97) = 5.295, p = 0.024) and "practicing the appropriate clinical reasoning process" (F(1,97) = 4.016, p = 0.038). According to multiple comparisons, the scores of "recalling appropriate history, physical examination, and tests on clinical hypothesis generation" (F(1,97) = 6.796, p = 0.011), "verbalizing and reflecting appropriately on own mistakes," (F(1,97) = 4.352, p = 0.040) "selecting keywords from the whole aspect of the patient," (F(1,97) = 5.607, p = 0.020) and "examining the patient while visualizing his/her daily life" (F(1,97) = 7.120, p = 0.009) were significantly higher in the control group. In the content analysis, 13 advantage categories of Hybrid PBL were extracted. In the subcategories, "acquisition of knowledge" was the most frequent subcategory, followed by "leading the discussion," "smooth discussion," "getting feedback," "timely feedback," and "supporting the clinical reasoning process." Hybrid PBL can help acquire practical knowledge and deepen understanding of clinical reasoning, whereas Pure PBL can improve several important skills such as verbalizing and reflecting on one's own errors and selecting appropriate keywords from the whole aspect of the patient.

This study aims to compare the effectiveness of Hybrid and Pure problem-based learning (PBL) in teaching clinical reasoning skills to medical students. The study sample consisted of 99 medical students participating in a clerkship rotation at the Department of General Medicine, Chiba University Hospital. They were randomly assigned to Hybrid PBL (intervention group, n = 52) or Pure PBL group (control group, n = 47). The quantitative outcomes were measured with the students’ perceived competence in PBL, satisfaction with sessions, and self-evaluation of competency in clinical reasoning. The qualitative component consisted of a content analysis on the benefits of learning clinical reasoning using Hybrid PBL. There was no significant difference between intervention and control groups in the five students’ perceived competence and satisfaction with sessions. In two-way repeated measure analysis of variance, self-evaluation of competency in clinical reasoning was significantly improved in the intervention group in "recalling appropriate differential diagnosis from patient’s chief complaint" (F(1,97) = 5.295, p = 0.024) and "practicing the appropriate clinical reasoning process" (F(1,97) = 4.016, p = 0.038). According to multiple comparisons, the scores of "recalling appropriate history, physical examination, and tests on clinical hypothesis generation" (F(1,97) = 6.796, p = 0.011), "verbalizing and reflecting appropriately on own mistakes," (F(1,97) = 4.352, p = 0.040) "selecting keywords from the whole aspect of the patient," (F(1,97) = 5.607, p = 0.020) and "examining the patient while visualizing his/her daily life" (F(1,97) = 7.120, p = 0.009) were significantly higher in the control group. In the content analysis, 13 advantage categories of Hybrid PBL were extracted. In the subcategories, "acquisition of knowledge" was the most frequent subcategory, followed by "leading the discussion," "smooth discussion," "getting feedback," "timely feedback," and "supporting the clinical reasoning process." Hybrid PBL can help acquire practical knowledge and deepen understanding of clinical reasoning, whereas Pure PBL can improve several important skills such as verbalizing and reflecting on one’s own errors and selecting appropriate keywords from the whole aspect of the patient.

The clinical reasoning skills is often gained when the biomedical knowledge is broadened and deepened alongside exposure to patients. The ‘ideal’ blend of axioms of clinical reasoning and case based learning would establish the pedagogical bridges right from the first year of medical education. So this study aimed to investigate the perceived importance and efficacy of teaching clinical reasoning skills among first year medical students, as this has not previously been described. As a priori, two clinical reasoning skill sessions were conducted using clinico-anatomical case vignettes designed according to the literature regarding clinical reasoning (‘serial cue’ approach and hypothetico-deduction). Students were divided into intervention and control group and crossed over in subsequent sessions. Analysis was done by mixed method approach including measuring proof of benefit using post-test comparison, quantitative survey and qualitative analysis by nominal group discussion. Post test scores were compared using student’s t-test. Feedbacks were analysed using descriptive statistics. The results showed that post test scores were significantly higher in intervention group than the control group in both sessions (P<0.001, 0.016). A total of 66% students felt, diagnostic skills and lateral thinking abilities were improved and It helped in developing problem-solving abilities for 67% students. clinico-anatomical case vignettes helped in understanding anatomical basis of clinical conditions for 61% students. To conclude, introducing clinical reasoning has considerable effect in improving the decision making ability of the students and if incorporated right from the first year, would better prepare the students in successful transition to clinical learning environment.

Purpose: Knowledge, clinical reasoning, and self-confidence are the basis for undergraduate education, and determine students’ level of competence. The purpose of this study was to assess the effects of the addition of a one-time simulation experience to the didactic curriculum on nursing students’ knowledge acquisition, clinical reasoning skill, and self-confidence. Methods: Using a quasi-experimental crossover design consisted of intervention and wait-list control groups. Participants were non-randomly assigned to the first intervention group (Group A, n=48) or the wait-list control group (Group B, n=46). Knowledge level was assessed through a multiple choice written test, and clinical reasoning skill was measured using a nursing process model-based rubric. Self-confidence was measured using a self-reported questionnaire. Results: Results indicated that students in the simulation group scored significantly higher on clinical reasoning skill and related knowledge than those in the didactic lecture group; no difference was found for self-confidence. Conclusion: Findings suggest that undergraduate nursing education requires a simulation-based curriculum for clinical reasoning development and knowledge acquisition.

Traditional didactic lecture-based models in stomatology education, which rely on passive learning through lectures and observation, have limitations in fostering clinical reasoning. This study aimed to assess the effectiveness of Computer-based Case Simulations (CCS) in enhancing the clinical reasoning skills of non-dental medical undergraduates, using the Mini-Clinical Evaluation Exercise (Mini-CEX) as an outcome measure. The study involved 328 non-dentistry medical undergraduates enrolled in four different educational programs: Bilingual, Pediatrics, Clinical Medicine I and Clinical Medicine II. Both the control and intervention group completed a Mini-CEX prior to training to establish a baseline. The control group received traditional didactic training (lectures + passive clinical observation), while the intervention group underwent CCS. Educational effectiveness was evaluated via theoretical test scores and Mini-CEX assessments. A pre-clerkship survey revealed that non-dentistry undergraduates prioritized learning about various dental diseases and developing clinical diagnostic and therapeutic thinking skills over the technical and procedural skills involved in the delivery of patient care. The intervention group, demonstrated significantly higher theoretical test scores compared with the control group across all classes (Bilingual Class: 98.1 ± 1.22 vs. 97.3 ± 0.97, Cohen's d = 1.129; Pediatric Class: 97.9 ± 0.85 vs. 96.5 ± 1.35, Cohen's d = 1.072; Clinical Medicine Class Ⅰ: 98.0 ± 0.91 vs. 97.0 ± 1.08, Cohen's d = 1.000; Clinical Medicine ClassⅡ: 99.2 ± 1.04 vs. 97.7 ± 1.74, Cohen's d = 1.432; all P < 0.05). There was no significant difference in the Mini-CEX score between the groups before the clerkship (P > 0.05). Although both groups showed improvements in Mini-CEX scores post-clerkship, the intervention group exhibited a significantly greater increase (Cohen's d > 0.5, P < 0.01), indicating superior clinical skill development. The results suggest that Computer-based case simulations (CCS) were associated with enhanced clinical knowledge and superior development of clinical reasoning skills in non-dentistry medical undergraduates compared to traditional methods, as measured by theoretical examination and Mini-CEX assessment. Future research should explore the long-term retention of clinical reasoning and the feasibility of scaling CCS in resource-limited settings.

BackgroundImproving clinical reasoning skills—the thought processes used by clinicians to formulate appropriate questions and diagnoses—is essential for reducing missed diagnostic opportunities. The electronic Clinical Reasoning Educational Simulation Tool (eCREST) was developed to improve the clinical reasoning of future physicians. A feasibility trial demonstrated acceptability and potential impacts; however, the processes by which students gathered data were unknown.ObjectiveThis study aims to identify the data gathering patterns of final year medical students while using eCREST and how eCREST influences the patterns.MethodsA mixed methods design was used. A trial of eCREST across 3 UK medical schools (N=148) measured the potential effects of eCREST on data gathering. A qualitative think-aloud and semistructured interview study with 16 medical students from one medical school identified 3 data gathering strategies: Thorough, Focused, and Succinct. Some had no strategy. Reanalysis of the trial data identified the prevalence of data gathering patterns and compared patterns between the intervention and control groups. Patterns were identified based on 2 variables that were measured in a patient case 1 month after the intervention: the proportion of Essential information students identified and the proportion of irrelevant information gathered (Relevant). Those who scored in the top 3 quartiles for Essential but in the lowest quartile for Relevant displayed a Thorough pattern. Those who scored in the top 3 quartiles for Relevant but in the lowest quartile for Essential displayed a Succinct pattern. Those who scored in the top 3 quartiles on both variables displayed a Focused pattern. Those whose scores were in the lowest quartile on both variables displayed a Nonspecific pattern.ResultsThe trial results indicated that students in the intervention group were more thorough than those in the control groups when gathering data. The qualitative data identified data gathering strategies and the mechanisms by which eCREST influenced data gathering. Students reported that eCREST promoted thoroughness by prompting them to continuously reflect and allowing them to practice managing uncertainty. However, some found eCREST to be less useful, and they randomly gathered information. Reanalysis of the trial data revealed that the intervention group was significantly more likely to display a Thorough data gathering pattern than controls (21/78, 27% vs 6/70, 9%) and less likely to display a Succinct pattern (13/78, 17% vs 20/70, 29%; χ23=9.9; P=.02). Other patterns were similar across groups.ConclusionsQualitative data suggested that students applied a range of data gathering strategies while using eCREST and that eCREST encouraged thoroughness by continuously prompting the students to reflect and manage their uncertainty. Trial data suggested that eCREST led students to demonstrate more Thorough data gathering patterns. Virtual patients that encourage thoroughness could help future physicians avoid missed diagnostic opportunities and enhance the delivery of clinical reasoning teaching.

Evaluating the effectiveness of illness script teaching on clinical reasoning skills in post-baccalaureate nursing students

Supplementing the Subinternship: Effect of E-Learning Modules on Subintern Knowledge and Confidence

To test the hypothesis that a screening and treatment intervention for early cryptococcal infection would improve survival among HIV-infected individuals with low CD4 cell counts. Newly enrolled patients at Family AIDS Care and Education Services (FACES) in Kenya with CD4≤100 cells/μl were tested for serum cryptococcal antigen (sCrAg). Individuals with sCrAg titre≥1:2 were treated with high-dose fluconazole. Cox proportional hazard models of Kaplan-Meier curves were used to compare survival among individuals with CD4≤100 cells/μl in the intervention and historical control groups. The median age was 34years [IQR: 29,41], 54% were female, and median CD4 was 43 cells/μl [IQR: 18,71]. Follow-up time was 1224 person-years. In the intervention group, 66% (514/782) were tested for sCrAg; of whom, 11% (59/514) were sCrAg positive. Mortality was 25% (196/782) in the intervention group and 25% (191/771) in the control group. There was no significant difference between the intervention and control group in overall survival [hazard ratio (HR): 1.1 (95%CI:0.9,1.3)] or three-month survival [HR: 1.0 (95%CI:0.8,1.3)]. Within the intervention group, sCrAg-positive individuals had significantly lower survival rates than sCrAg-negative individuals [HR:1.8 (95%CI: 1.0, 3.0)]. A screening and treatment intervention to identify sCrAg-positive individuals and treat them with high-dose fluconazole did not significantly improve overall survival among HIV-infected individuals with CD4 counts≤100 cells/μl compared to a historical control, perhaps due to intervention uptake rates or poor efficacy of high-dose oral fluconazole.

PurposeThe Accreditation Council for Graduate Medical Education (ACGME) restricted the duty hours for residents training in 2004. With less time to learn medicine, residents may not develop the clinical reasoning skills needed. Simulation can provide a remedy for this lack of time by allowing residents to practice skills and develop clinical reasoning in a simulated environment. Simulation Wars (SimWars), a clinical reasoning simulation has been shown to improve clinical reasoning skills. The purpose of the study was to investigate the effect of Simulation Wars on In-Training Examination (ITE) Scores and Global Rating Scale (GRS) Scores in Emergency Medicine (EM) residents.MethodsThe Quasi-Experimental design was used in this retrospective study. The main comparison was between historical controls, the residents who did not participate in the Simulation Wars, and the intervention group comprised of residents who participated in the SimWars.ResultsA total of 127 residents were participants in this study including 70 from the intervention and 57 from the historical control group. There were no significant differences found in GRS scores between both groups except for Communication and Professionalism (p<0.001). No overall improvement in ITE scores for the control group and for the intervention group was found. Furthermore, within the intervention group, while comparing those residents who participated in certain subcategories of SimWars and those who did not, there was a significant improvement in ITE scores in the subcategories of Thoracic Disorders, Abdominal/Gastrointestinal, Trauma Disorders and OBGyn.ConclusionSimWars in the subcategories of Abdominal/Gastrointestinal, Thoracic, OBGyn and Trauma were found to be associated with improved ITE scores in those subcategories. Since Emergency Medicine utilizes extensive clinical reasoning skills, SimWars may provide better educational opportunities for EM residents.

Clinical reasoning is the process of reasoning to decide for managing the patient using data and applying medical knowledge and experience. Clinical reasoning skills are essential skills for the novice learner of medical education to learn the process of clinical diagnosis, thereby providing safe and effectual health care. These skills learning help clinicians arrive at a diagnosis and prevent making diagnostic errors which are reported to occur in five to 15% of cases. Poor clinical reasoning leads to a diagnostic error which may jeopardize the patient’s safety. The clinical reasoning skills are not generally explicitly imparted to the learners especially during their undergraduate learning period even though these may be documented in the curriculum of medical undergraduate study. The key elements in the clinical reasoning process are the patients’ story, data acquisition, problem representation, hypothesis generation, search and selection of illness script, differential diagnosis, and a leading diagnosis. Clinical reasoning is a complex process, difficult to teach learners and assess their skills, consumes clinical medical educators’ time, and requires resources for teaching and learning. There must be educational strategies both at the undergraduate and postgraduate levels to promote diagnostic reasoning skills; for this, clinical medical educators must be acquainted/trained in how to convey the reasoning approaches to beginners. The clinical medical educator has to a play dual role; provide quality care to the patients, teach clinical reasoning skills to the learners, and assess their skills to make them independent decision-makers and problem solvers in clinical settings. Clinical reasoning skills are among the core competencies to be learned by medical learners to become competent clinicians. The clinical competence of the clinician cannot be superseded by the advancement of technology and evidence-based medicine. All these three need to be integrated to minimize the errors in diagnosis. Clinical educators must unequivocally nurture and enhance the capacity of learners to include and integrate both analytical and non-analytical clinical reasoning strategies into their approach to arrive at diagnosis. The clinical medical educator must identify the learners’ approach to clinical reasoning and enable them to follow the right approaches towards clinical reasoning. Clinical reasoning skills are better learned/imparted during clinical encounters and deliberate practice enriches learning of these skills. Enhancement of clinical reasoning skills learning can be achieved through deliberate practice. The clinical medical educator may organize and supervise the simulation-based deliberate practice sessions for the learners to boost their clinical reasoning skills. For the deliberate practice of clinical reasoning skills, The New England Journal of Medicine (NEJM) has developed an application NEJM Healer, a screen-based interactive patient encounter (Virtual Bedside Encounter) through which learners are involved in each element of clinical reasoning process. Virtual Reality (VR) is also gaining popularity in educating the medical students and has been demonstrated to be beneficial in enhancing students’ comprehension and memory as well as in the development of transferable skills like surgical methods. The medical schools in South Asian countries need to reiterate the development/enhancement of clinical reasoning skills of both medical undergraduate and postgraduate learners. To achieve this objective, medical colleges must regularly organize training for clinical medical educators to facilitate students’ learning in reasoning skills, and for assessing their skills, and provide feedback to the learners. The institutes should also invest in infrastructure to pursue the use of modern technologies like VR, skills labs, etc. to attain this objective.