I believe like that RADICAL transformation is needed and can be realized in nursing education today. I have crafted a document: “A Declaration to Transform Nursing Education” that situates 7 needed practical paradigm shifts to help make needed transformation in nursing education a reality.
The 4th paradigm shift of this document and topic of todays blog: I will embrace clinical reasoning as a pedagogy that promotes nurse thinking and will situate this in my classroom and clinical settings.
Failure to Rescue
The image on this blog post is a graphic metaphor of what can happen in practice if the nurse does not identify or recognize a struggling patient also in need of “rescue.” They may go down for the last time!
Del Bueno identified in her research that the use of NANDA taxonomy was a BARRIER to new nurses to properly identify the care priority with scenarios that required the nurse to intervene with a simple status change (4). I discuss this in more depth in a recent blog post, I see Dead Patients.
NANDA vs Clinical Reasoning
The traditional use of NANDA nursing diagnostic statements to situate care priorities is best suited as a FUNDAMENTAL level of nurse thinking that has relevance to STABLE patients with EXPECTED outcomes. Then at the second year/advanced level of nursing education, CLINICAL REASONING must be taught, understood and applied to practice.
When a patient’s status changes and requires “rescue”, NANDA must not be taught to make a nursing diagnostic statement “fit”, but clinical reasoning will be the best approach to prepare students for practice, will facillitate patient “rescue,” and improve patient outcomes!
In order to transform nursing education, CLINICAL REASONING must be front and center in nursing curriculum and situated in both the clinical and classroom settings. This is an essential paradigm shift identified by the Carnegie Foundation’s educational research headed by Patricia Benner in Educating Nurses: A Call for Radical Transformation.
If nurse educators are to have credibility with our students, we too must embrace educational BEST PRACTICE if we expect our students to use nursing interventions based on BEST PRACTICE in our programs.
Five “Rights” Revisited
But in addition to the 5+ “rights” related to safe med administration that every student and educator can readily list from memory, can you readily identify and list the 5 “rights of clinical reasoning?
Did you even know that there are 5 “rights” related to clinical reasoning (1)? If you were not even aware that these “rights” existed in the literature, NOW is the time to identify, memorize, APPLY, and INTEGRATE into your curriculum so students can be prepared for practice! But before we go there, let’s lay a foundation that includes a DEEP understanding of clinical reasoning.
Clinical Reasoning Defined:
The ability of the nurse to THINK IN ACTION and REASON as a situation CHANGES over time by capturing and understanding the significance of clinical trajectories and grasping the essence of the current clinical situation (2).
The ability of the nurse to focus and filter clinical data in order to recognize what is most and least important (what data is RELEVANT) so a problem can be identified if present (3).
Patient’s in any care setting rarely stay static, they either improve or can begin to swirl in the wrong direction and require the nurse to recognize the need to “rescue” before it is too late. This is the strength of clinical reasoning when APPLIED to practice.
“Five Rights” of Clinical Reasoning
Let’s make it a priority in nursing education to make the following 5 “rights” just as well known and memorized by every student who leaves our program to ensure SAFE practice!
Cues are the clinical data collected and clustered by the nurse. Recognizing the RELEVANCE and RELATIONSHIPS of this data and contextualizing to your patient is the essence of this “right.” When EARLY cues are missed or not identified, allowing a complication to progress is a classic example of “failure to rescue” by the nurse.
This “right” is not about checking the name and date of birth of your patient, but the importance of the nurse to identify if your patient is high risk for developing a potential complication. The nurse must be able to recognize that an 18-year-old with an appendectomy is not as likely to develop a complication as a patient with the same problem who is 78!
This refers to the timeliness of identifying a high risk patient among multiple patients you may be caring for. Recognizing EARLY signs of a complication and then initiating nursing interventions at the RIGHT time and in the RIGHT sequence is imperative. Remember that “failure to rescue” is not only missing a complication that develops but also when nursing/medical interventions are started too late.
Once a clinical judgment is made, the right action or intervention must be undertaken by the nurse. Did you know that on a typical med/surg floor over an 8-hour shift a typical nurse engages in 50 significant clinical reasoning concerns that require a clinical judgment?
Clinical data that suggests a potential complication must be acted upon. The consequences of an incorrect clinical judgment can make the difference between life and death. In one study, one half of patients who had cardiac arrests on the floor of a hospital had clinical signs of deterioration 24 hours before the arrest but were NOT acted upon by the nurse.
The right reason is not just making the correct reasoning that leads to a nursing judgment, but understanding the RATIONALE or WHY of everythig that is done in practice by the nurse. In order to do this consistently the nurse must be able to apply clinical reasoning to the bedside which include grasping the essence of the current situation and put the clinical puzzle together to see the big picture (1).
TEMPLATE of Clinical Reasoning Questions
I have created a highly sought out and utilized “tool of transformation,” a progressive step-by-step breakdown of clinical reasoning questions (13) that a nurse uses in practice BEFORE seeing the patient as well as during care. For second year students, FLIP your clinical and use this template od clinical reasoning instead!
Rob Morris, RN, MSN , Nursing Faculty, College of the Sequoias, Vasalia, California took the plunge. This is his response: “I just finished my first clinical rotation of using Keith’s Clinical Reasoning Care Plan instead of our traditional care plan. Great success! The students loved it, I loved it, and they report feeling much better prepared for patient care.”
This can be your experience as well. Obtain this FREE template of clinical reasoning questions and see for yourself! My new book THINK like a Nurse! also situates clinical reasoning in depth to help students grasp this essential concept to practice. If you an educator, this book will help deepen your understanding so it can be taught well. This book was written for nursing students and is a rich resource that will lay a strong foundation for clinical practice!
It is my hope and prayer that you will catch the vision to make clinical reasoning the centerpiece of your program, and be a part of the needed transformation in nursing education to promote better outcomes for the patients our students will soon care for!
1. Levett-Jones, T., Hoffman, K., Dempsey, J., Yeun-Sim Jeong, S., Noble, D., Norton, C…Hickey, N. (2010). The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients, Nurse Education Today, 30, 515-520.
2. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass
3. Benner, P., Hooper-Kyriakidis, P. & Stannard, D. (2011). Clinical wisdom and interventions in Acute and Critical Care: A thinking-in-action approach.(2nd). New York, NY: Springer.
4. Del Bueno, D. (2005). “A Crisis in Critical Thinking,” Nursing Education Perspectives, 26(5), 278-282.
Keith Rischer – Ph.D., RN, CCRN, CEN
As a nurse with over 35 years of experience who remained in practice as an educator, I’ve witnessed the gap between how nursing is taught and how it is practiced, and I decided to do something about it! Read more…
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