Last week I discussed the importance of clinical reasoning as the most important concept that must be emphasized in order to bring needed transformation.
There are two words that are foundational to clinical reasoning that are essential for new novice nursing students to develop clinical reasoning skills and strengthen their professional progression as developing nurses.
These two words are relevance and priority.
When relevant data goes unrecognized by the bedside nurse, a change of status can go unrecognized and progress until it may be too late. As a rapid response nurse in the critical care float pool, I have seen this tragic reality firsthand when early signs of sepsis that included restlessness, tachycardia, and tachypnea went unrecognized or misinterpreted by the nurse until it was too late.
When I was recently called to respond to a rapid response page, the patient was an elderly woman 1 day post-op. Four hours ago the patient was restless, and tachycardic with HR 100’s. Now the patient was unresponsive, RR 40’s, HR 120’s, cool, and diaphoretic. The blood pressure had not been checked in four hours and at that time was 158/90. When I rechecked it it was 68/30! Despite an emergent transfer to ICU and three vasopressors, this patient later died in part because of the nurse’s inability to recognize relevant clinical data and initiate interventions to “rescue” with this change of status.
Novice to Expert
According to Patricia Benner and her novice to expert theory of professional progression for nurses, novice nursing students are concrete learners who see every thing including all content taught and clinical data in the medical record as relevant. They are unable to distinguish what is relevant or most important because of their lack of clinical experience.
As students progress to an advanced beginner in the final year of the program, they begin to recognize some relevance of clinical data, but because of their lack of clinical experience continue to struggle with setting proper priorities at the bedside (1).
Therefore, the two aspects of clinical reasoning that must be continually emphasized in both the classroom and clinical settings are RELEVANCE as well as what are the nursing, medical, and educational PRIORITIES for every patient they care for.
In the Classroom
As educators we must understand the importance of addressing this obvious weakness of nursing students and the need to emphasize relevance of content and establishing priorities in our classroom setting.
For example, not everything in the chapter reading is essential or relevant to student learning of what they will experience or encounter in practice. Identify the pages that are NEED to know for class, and let them read the NICE to know if they choose.
Embrace your role as a filter of content to emphasize and teach the most important aspects of any content so students acquire a DEEP learning of what is most important. This is in contrast to the SKIN deep learning of a broad body of content that limits the ability of a student to readily apply classroom content to the bedside.
Make it a priority in every classroom lecture to address and emphasize the nursing priorities that correlate with your content and a plan of care that flows from this priority. Discuss the most likely complications that can occur.
In the Clinical
The clinical setting for most students is a perpetual struggle of TMI! Depending on how long the patient has been in the hospital or clinical setting you are in, there will be numerous lab panels, radiology reports, and physician and nursing progress notes students must sift through.
If you are an experienced nurse, it is easy to take for granted the 10 to 12 labs that are on a basic metabolic panel (BMP) as well as a complete blood cell count (CBC). But is every lab value relevant to the nurse on these panels?
From my perspective I would say absolutely not! We can emphasize relevance by helping our students to see that there are certain labs that are always relevant because of their importance to physiologic functions.
For example on a basic metabolic panel; sodium, potassium, and creatinine are the most important and relevant labs that must always be noted and I consider always relevant. The other labs may or may not be that relevant based on the reason the patient is in the hospital.
In the same way, on a CBC panel, the most important labs that I want my students to note are the WBC, neutrophil, and hemoglobin lab values. These three labs are the most important and also are always relevant to the nurse. As educators we must take the volume of content in the clinical setting and help to streamline what aspects are most important so students acquire the deep learning of what is most important in this setting that include the daily care providers note if present.
Relevant Assessment Data
This emphasis of relevance in the clinical setting can be carried through to patient care. After the student has collected the initial set of vital signs and nursing assessment, it is important for the clinical educator to touch base early in the clinical and ask each student what data that was personally collected is most important or relevant and has the nursing priority changed as a result of what was personally collected and assessed.
Priority setting can be carried through to include not only the nursing care priority but also the educational priority for each patient that a student cares for. I find that many students are uncomfortable embracing the role of nurse as educator because of their limited experience. But encourage your students to identify what is the current educational priority that they can address and then teach their patient.
By emphasizing these themes of most important or relevance of content and clinical data as well as priority setting, nurse educators can make a difference to intentionally guide and develop these needed aspects of professional development that are inherently weak because of their lack of clinical experience.
In my template of clinical reasoning questions to develop nurse thinking handout, I also intentionalize and emphasize the importance of priority setting and relevance as I break down clinical reasoning step-by-step into bite-size pieces so students can readily grasp this essential nurse thinking skill and apply it to the bedside.
CLICK HERE to download my newly revised “Template of Clinical Reasoning Questions to Develop Nurse Thinking” and several other clinical reasoning resources!
I am committed to partnering with any nurse educator who desires to be the needed change by emphasizing clinical reasoning in the curriculum. Please do not hesitate to contact me if you have any questions or comments as you step out into the deep waters of transformational change by making RELEVANCE and PRIORITY setting foundational to deepen the thinking of your students and improve the outcomes of the patients they will soon be caring for!
Question for discussion in your department:
How is our program integrating relevance and priority setting in both the clinical and classroom settings? What could be done differently to bring needed change?
1. Benner, P. (1982). From novice to expert. American Journal of Nursing, 82(3), 402–407.