Using ‘think aloud’ as a strategy for improving clinical reasoning in high fidelity case-based simulation for undergraduate nursing students.

Theme Paper for Curriculum innovation and enhancement theme AIM: This paper reports on a research project that trialled an educational strategy implemented in an undergraduate nursing curriculum. The project aimed to explore the effectiveness of ‘think aloud’ as a strategy for improving clinical reasoning for students in simulated clinical settings. BACKGROUND: Nurses are required to apply and utilise critical thinking skills to enable clinical reasoning and problem solving in the clinical setting (Lasater, 2007). Nursing students are expected to develop and display clinical reasoning skills in practice, but may struggle articulating reasons behind decisions about patient care. The ‘think aloud’ approach is an innovative learning/teaching method which can create an environment suitable for developing clinical reasoning skills in students (Banning, 2008, Lee and Ryan-Wenger, 1997). This project used the ‘think aloud’ strategy within a simulation context to provide a safe learning environment in which third year students were assisted to uncover cognitive approaches to assist in making effective patient care decisions, and improve their confidence, clinical reasoning and active critical reflection about their practice. MEHODS: In semester 2 2011 at QUT, third year nursing students undertook high fidelity simulation (some for the first time), commencing in September of 2011. There were two cohorts for strategy implementation (group 1= used think aloud as a strategy within the simulation, group 2= no specific strategy outside of nursing assessment frameworks used by all students) in relation to problem solving patient needs. The think aloud strategy was described to students in their pre-simulation briefing and allowed time for clarification of this strategy. All other aspects of the simulations remained the same, (resources, suggested nursing assessment frameworks, simulation session duration, size of simulation teams, preparatory materials). Ethics approval has been obtained for this project. RESULTS: Results of a qualitative analysis (in progress- will be completed by March 2012) of student and facilitator reports on students’ ability to meet the learning objectives of solving patient problems using clinical reasoning and experience with the ‘think aloud’ method will be presented. A comparison of clinical reasoning learning outcomes between the two groups will determine the effect on clinical reasoning for students responding to patient problems. CONCLUSIONS: In an environment of increasingly constrained clinical placement opportunities, exploration of alternate strategies to improve critical thinking skills and develop clinical reasoning and problem solving for nursing students is imperative in preparing nurses to respond to changing patient needs.

What factors influence nurses’ assessment practices? Development of the Barriers to Nurses’ use of Physical Assessment Scale

Aim To develop and psychometrically test the Barriers to Nurses’ use of Physical Assessment Scale. Background There is growing evidence of failure to recognise hospitalised patients at risk of clinical deterioration, in part due to inadequate physical assessment by nurses. Yet, little is known about the barriers to nurses’ use of physical assessment in the acute hospital setting and no validated scales have been published. Design Instrument development study. Method Scale development was based on a comprehensive literature review, focus groups, expert review and psychometric evaluation. The scale was administered to 434 acute care registered nurses working at a large Australian teaching hospital between June and July 2013. Psychometric analysis included factor analysis, model fit statistics and reliability testing. Results The final scale was reduced to 38 items representing seven factors, together accounting for 57.7% of the variance: (1) reliance on others and technology, (2) lack of time and interruptions, (3) ward culture, (4) lack of confidence, (5) lack of nursing role models, (6) lack of influence on patient care, and; (7) specialty area. Internal reliability ranged from .70 to .86. Conclusion Findings provide initial evidence for the validity and reliability of the Barriers to Nurses’ use of Physical Assessment Scale and point to the importance of understanding the organisational determinants of nurses’ assessment practices. The new scale has potential clinical and research applications to support nursing assessment in acute care settings.

Nursing Management : Fluid, Electrolyte, and Acid-Base Imbalances

Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 4th Edition is the most comprehensive go-to reference for essential information about all aspects of professional nursing care of patients. Using the nursing process as a framework for practice, the fourth edition has been extensively revised to reflect the rapid changing nature of nursing practice and the increasing focus on key nursing care priorities. Building on the strengths of the third Australian and New Zealand edition and incorporating relevant global nursing research and practice from the prominent US title Medical-Surgical Nursing, 9Th Edition, Lewis’s Medical-Surgical Nursing, 4th Edition is an essential resource for students seeking to understand the role of the professional nurse in the contemporary health environment.

The primacy of vital signs – Acute care nurses’ and midwives’ use of physical assessment skills: A cross sectional study

BACKGROUND: Registered nurses and midwives play an essential role in detecting patients at risk of deterioration through ongoing assessment and action in response to changing health status. Yet, evidence suggests that clinical deterioration frequently goes unnoticed in hospitalised patients. While much attention has been paid to early warning and rapid response systems, little research has examined factors related to physical assessment skills. OBJECTIVES: To determine a minimum data set of core skills used during nursing assessment of hospitalised patients and identify nurse and workplace predictors of the use of physical assessment to detect patient deterioration. DESIGN: The study used a single-centre, cross-sectional survey design. SETTING and PARTICIPANTS: The study included 434 registered nurses and midwives (Grades 5-7) involved in clinical care of patients on acute care wards, including medicine, surgery, oncology, mental health and maternity service areas, at a 929-bed tertiary referral teaching hospital in Southeast Queensland, Australia. METHODS: We conducted a hospital-wide survey of registered nurses and midwives using the 133-item Physical Assessment Skills Inventory and the 58-item Barriers to Registered Nurses’ Use of Physical Assessment scale. Median frequency for each physical assessment skill was calculated to determine core skills. To explore predictors of core skill utilisation, backward stepwise general linear modelling was conducted. Means and regression coefficients are reported with 95% confidence intervals. A p value < .05 was considered significant for all analyses. RESULTS: Core skills used by most nurses every time they worked included assessment of temperature, oxygen saturation, blood pressure, breathing effort, skin, wound and mental status. Reliance on others and technology (F = 35.77, p < .001), lack of confidence (F = 5.52, p = .02), work area (F = 3.79, p = .002), and clinical role (F = 44.24, p < .001) were significant predictors of the extent of physical assessment skill use. CONCLUSIONS: The increasing acuity of the acute care patient plausibly warrants more than vital signs assessment; however, our study confirms nurses’ physical assessment core skill set is mainly comprised of vital signs. The focus on these endpoints of deterioration as dictated by early warning and rapid response systems may divert attention from and devalue comprehensive nursing assessment that could detect subtle changes in health status earlier in the patient's hospitalisation.

Phantom limb pain: A nursing perspective

Phantom limb pain (PLP) is a neuropathic pain condition occurring after amputation of a limb. PLP affects amputees’ quality of life and results in loss of productivity and psychological distress. The origin of pain from a non-existing limb creates a challenging situation for both patients and nurses. It is imperative to provide patients and nurses with the knowledge that PLP is a real phenomenon that requires care and treatment. This knowledge will lead to reduced problems for patients by allowing them to talk about PLP and ask for help when needed. Understanding of this phenomenon will enable nurses to appreciate the unique features of this form of neuropathic pain and apply appropriate techniques to promote effective pain management. Performing accurate and frequent assessments to understand the unique characteristics of PLP, displaying a non-judgemental attitude towards patients and teaching throughout the peri-operative process are significant nursing interventions.

Have OSCEs come of age in nursing education?

This article is intended to contribute to the current debate as to whether the objective structured clinical examination (OSCE) should become a standard assessment tool for undergraduate nursing education as they currently are for medicine. The authors describe how one UK university developed an OSCE for a nursing undergraduate programme with the aim of emphasising the need for nursing students to be competent in clinical skills and offering a means of standardising the assessment of these skills. There has been an increasing number of research studies carried out in this area at international level and this article's main contribution to the literature is the description of the Angoff standard-setting procedure that was used to calibrate the OSCE at this University and which makes it the first nursing OSCE in the UK to incorporate a scientific standard-setting procedure.

Assessment of tuberculosis treatment accessibility for patients co-infected or not with the human immunodeficiency virus

This study aimed to evaluate accessibility to treatment for people with TB co-infected or not with HIV. This cross-sectional study addressed issues regarding accessibility to treatment in a city in the interior of Sao Paulo state, Brazil. The instrument Primary Care Assessment Tool was utilized with 95 people. To evaluate access to treatment, Student's t test was used. The mean scores of variables were analyzed separately and compared between two groups (people with TB co-infected with HIV and people with TB not co-infected with HIV). Mean scores showed that HIV co-infected people presented greater difficulties in gaining access than those not co-infected. Professionals visited co-infected people more often when compared to those not co-infected; the co-infected people almost never accessed treatment for their disease in the Health Unit nearest their home. There is, therefore, the need for greater integration and communication between the programs for treatment of Tuberculosis and STD/AIDS.