The effect of curricula approaches to the development of the student ’ s clinical reasoning ability

Curationis 28(2): 70-76 A comparative analysis was undertaken using descriptive and cross sectional survey design, to explore the effect of Problem Based Learning and Traditional approach on the development of clinical reasoning abilities of nursing students. Using quota sampling, a sample of 87 subjects was used from two University Nursing Departments, each using these curricula approaches. Students from their first, second and fourth year were interviewed, using the Triple Jump Exercise as an instrument to collect data. Data analysis using the SAS computer software package was employed to obtain both descriptive and statistical summarizations. Though descriptive analysis o f the scores of clinical reasoning showed a slight difference between the two curricular approaches, this was not confirmed statistically as the two factor ANOVA and Tukey’s methods revealed no significant differences by approaches. The only significant difference was revealed between the students’ levels of study with senior levels (4th years) outperforming their juniors. These findings therefore conclude that, students using Problem Based Learning and Traditional approach perform on a similar level in clinical reasoning.


Introduction
With the transformation of the health and education systems in South Africa, the South African Nursing Council (SANC) e m p h a siz e d te a c h in g and le a rn in g strategies that w ill enhance studentcentred education and training with a focus on the com m unity health needs (SANC 1999).In response to this, Nursing Education Institutions have begun to introduce innovative approaches like Com m unity Based Education (CBE); Problem Based Learning (PBL) and Case Based Learning (CBL).The adoption of problem based learning as a curriculum approach was viewed as an effort to move away from the content-focused learning approach.This was seen as an effort to develop students' critical and clinical reasoning abilities together with self directed learning (Barrows, 1985:59;Boud and Felleti, 1991:104).
Clinical reasoning skills are seen as the c o rn e rsto n e fo r su c c e ssfu l n u rsin g p ra c tic e .V arious a u th o rs h av e conceptualised clinical reasoning as encompassing all the thinking processes nurses engage in during their practice.Barrow and Pickel (1991: 76) defined clinical reasoning as: a dynamic, cyclical, reiterative process in which observation, a n a ly sis, s y n th e sis, d e d u c tio n , in d u c tio n , h y p o th e s is g e n e ra tio n , h y p o th esis testin g , in q u iry -stra teg y design and the skills o f examination are all in terrelated (B arrow , 1994:125).Therefore, clinical reasoning, clinical decision making, clinical judgem ent and the scientific method are seen as terms used interchangeably.Others view critical thinking as a com ponent o f clinical re a so n in g in n u rsin g p ra c tic e (McCloskey & Grace, 1997:64;Girot, 2000:93).On the other hand, some view clinical reasoning as a com ponent of critical thinking.In their model of critical thinking , in an a ttem p t to p ro v id e a dom ain specific definition o f critical thinking, K ataoka-Yahiro and Saylor described critical thinking as a reflective and reasonable thinking about nursing problems without a single solution which is focused on deciding what to believe and do.They further stress that critical th in k in g c o m p e te n c ie s in c lu d e diagnostic reasoning, clinical reasoning, clinical decision m aking and the nursing p ro c e s s .T h e s e c o n c e p tu a lis a tio n s account for the overlap in the usage of the concept clinical reasoning and critical thinking in nursing practice (Kataoka-Yahiro& Saylor 1994:309).
Clinical supervision, according to Jenks, 1993 is a regular, p rotected tim e for facilitated, in-depth reflection on clinical practice w ith an aim o f h elp in g the student to achieve, sustain and creatively d e v e lo p a h ig h q u a lity o f p ra c tic e th ro u g h fo c u s e d s u p p o rt and d e v e lo p m e n t.T h e r e f o r e , c lin ic a l supervision is the um brella term used to describe the m ethods used by teachers to help students in their developm ent of clinical reasoning (Jenks, 1993 :399).
To date much has been written about the e ffe c tiv e n e s s o f P B L e s p e c ia lly in medical education (Barrows, 1994:236;Hawkins 2002:215;D avis & H arden, 1999:37;Mhlauli & K hanyile, 1999:53;Khumalo & Gwele 2000:108), and most research on this approach has been on the a ttitu d e s o f n u rse e d u c a to rs , students; and implementation problems.The reason for this may be that PBL has been a relatively new concept in South Africa and hence the focus has been only on its acceptability and im plem entation.
On th e o th e r h a n d , a s tu d y w as conducted by M tsh ali and K hanyile (2001:89), to compare the ethical decision m aking sk ills o f stu d e n ts from both approaches.A ccording to the results, there w as no s ig n ific a n t d iffe re n c e betw een the tw o groups o f stu d e n ts' ethical decision making skills.It becomes evident then that, although m uch has been written about the potential benefits of PBL, there is little em pirical evidence to support this.

Problem statement
T he u se o f th e se tw o c u r r ic u la r approaches in pre-registration programs, that is p ro b lem b a se d le a rn in g and traditional content-based approach, has raised much interest and debate as to whether it is the approach alone, or there are oth er factors that will ensure the p ro d u c tio n o f c o m p e te n t n u rse p ra c titio n e r s w ith e x p e rt c lin ic a l reasoning skills essential for providing highly skilled quality care grounded in so u n d k n o w led g e o f the scien ce o f nursing.In clinical teaching situations, endeavours are m ade to link w hat is tau g h t in the classro o m and w hat is experienced in the clinical setting thus bridging the theory-practice gap.This is d o n e to e n su re d e v e lo p m e n t o f com petent practitioners with the ability to provide safe, com petent care which T a y lo r (2 0 0 0 :8 4 0 ), d e s c rib e s as depen d ing on good clin ical problem solving skills.It becom es im perative therefore to gain better understanding of c o g n itiv e problem solving strategies used by nurses in clinical practice and a p p ro a c h e s th a t b e st e n h a n c e th is development.The question is: which of the tw o approaches best enhance the d e v e lo p m e n t o f c lin ic a l re a so n in g ability?

Purpose of the study
T h e stu d y s o u g h t to e x p lo re and describe the effect o f problem based learning and the traditional approach to the development of the students' clinical learning abilities.

Research questions
1 How do the clinical reasoning abilities o f b a sic n u rsin g stu d e n ts from the traditional approach com pare with those fro m th e P ro b le m B a se d L e a rn in g approach? 2 Is there progression in the development o f students' clinical reasoning abilities as th e y p ro g re ss w ith in th e tw o programs?

Hypothesis
It was hypothesised that, between the two groups of students: 1 Clinical reasoning skills o f the group following the PBL approach will be better than th o se fo llo w in g the trad itio n a l approach.2 The progression in the development of clinical reasoning skills from entry to exit will be higher for the PBL group than the traditional group.

Clinical reasoning
In the context o f this study, clinical reasoning is a dynamic, cyclic, reiterative process in which observation, analysis, s y n th e s is , d e d u c tio n , in d u c tio n , h y p o th e sis g e n e ra tio n , h y p o th e sis testing, inquiry-strategy design and the skills o f exam ination are interrelated (Barrow & Pickel, 1991:121).The terms clinical ju d gem ent, clin ical decision making and problem solving, clinical reasoning has been used synonymously and in te rc h an g e ab ly th ro u g h o u t the study.

Studen t
A person follow ing the basic nursing pro g ram m e acc o rd in g to the South African Nursing Council regulation R425 of 1985 as amended.Comprehensive basic nursing programme An integrated basic nursing programme offered either at a degree or diploma level, with a duration o f 4 years, leading to registration as a general nurse, midwife, psychiatric and community health nurse (SANC, 1985).

Teaching approach
Strategies o f instruction and learning used in the teaching -learning situation.

Traditional approach
A d id a c tic m odel u se d to d e liv e r instruction both in the classroom and clinical settings is used with more reliance on content co v erage and o b jec tiv e s testing.

Problem -b ased learning
In this approach, active involvement of the student is fostered and the role of the teacher is facilitative with learning resulting from the process o f working towards the understanding or resolution of a problem (Barrows, 1985:104).

(c) Inquiry stage
This step aims at obtaining more or new in fo rm a tio n b e y o n d th a t in itia lly presented.Barrow and Pickel (1991:68), view this stage as a disciplined, logical, vertical, deductive cogn itiv e process used to select particular strategies and clinical skills to be used for data collection in support or refuting the hypothesis.

(d) Data analysis and synthesis
Data accum ulated during the inquiry stage need to be o rg an ized so as to fo rm u la te the p ro b lem .H y p o th esis testing occurs during this stage as well as the identification o f cause and effect relationships.

(e) Diagnostic and treatm ent decision
This is the end result of clinical reasoning that ends the enco u n ter betw een the n u rse an d the p a tie n t.T h e nurse clinician decides what the underlying responsible mechanism involved in the patient's problem is and selects strategies to modify, correct or manage the problem identified.

Target population
The target population consisted of all students following the degree in Nursing (General, Community, Psychiatry) and M id w ife ry a c c o rd in g to SA N C R e g u la tio n R 425 at tw o se le c te d universities in the country.One group from one university was using PBL whilst the o th e r g ro u p from the seco n d u n iv ersity w as using the trad itio n al approach.T here w as a total o f 180 students from institution A (PBL group) and a to ta l o f 2 3 4 s tu d e n ts from institution B (Traditional group).

Sampling and sampling technique
Quota sampling was used where 10% of the first year group was sampled from each university, 45% second year and 45% fourth years as indicated in table 1.The sam ple o f l sl year students was deliberately minimal since they were only included to obtain baseline information while 2nd and 4 lh year students were included as they met the eligibility criteria for a minimum period of clinical exposure in medical and surgical units o f plus minus 1 year.Third year students were excluded as it was felt that the difference of a year between the levels would not give a much observable picture of the s tu d e n ts ' p ro g re ssio n in c lin ic a l reasoning skills.The progression was to be observed from the 2nd to the 4"1 level.

Data collection procedures
The Triple Jump Exercise was used as an instrum ent to collect data.The Triple Jump Exercise is a structured exercise consisting of three parts or steps which are the (a) p ro b lem d e fin itio n , (b) inform ation search and study and (c) problem sy n th e sis fo rm u la tio n and intervention.It is an experiential exercise which allows the student to observe and evaluate problem solving behaviours while simultaneously verifying their self a w a re n e ss w ith a n o th e r p e rso n (examiner).The objectives o f using this exercise are to assess the individual student's ability to generate hypothesis from a given situation, seek out and critique relevant data, develop either a diagnosis or management (care) plan to evaluate his or her own performance in the exercise (Vernon & Blake, 1993:559).The T riple Jum p E xercise is a w ellrecognized approach to assess problem solving and critical thinking skills.This exercise is commonly used by institutions using the PBL approach, however both institutions in the study were not using Triple Jump in other words both groups were not fam iliar with the exercise, although Institution B was using PBL as an approach to teaching and learning.T he in stru m e n t w as a d m in is te re d through individual interviews with the two groups o f students from the two universities.A clinical scenario was used to present the subjects with a problem for analysis.The scenario analysis was allocated 30 minutes, after which each subject was evaluated in all 4 phases (problem definition, data collection, p ro b lem d e fin itio n and n u rsin g intervention) of the instrument.Using the questions in the evaluator's notes as an interview guide, resp o n ses w ere elicited from subjects.Subjects were to think aloud when analysing  D e s c rib e th e n u rsin g intervention you will initiate, g iv in g a ratio n ale for each action.
W hat nursing intervention will you initiate and why? interviews and thereafter comparing their ratings.M oderation o f the scores was also a team effort by the researcher and the two research assistants.

Validity
Content validity was ensured by using the T riple Jum p E xercise as the data collection in stru m en t.A s m entioned earlier, the Triple Jump Exercise has a selfe v id e n t m e a s u re o f th e a d e q u a te co verag e o f all th e e le m e n ts o f the concept clinical reasoning that this study sought to investigate.

Ethical considerations
Permission was obtained from the Heads of the two institutions and the subjects all signed an in fo rm ed consent.N o names were used in the researcher's notes and evaluation form s. Pre-determ ined c o d e s w e re u s e d to id e n tif y th e information with the subject from each g ro u p .S u b je c ts w e re a s s u re d o f anonymity.

Data analysis
T h e ra tin g a n d m o d e ra tio n o f th e subjects' responses was done jointly by the research team.Narratives were rated on a five item scale used for the Triple Jum p Evaluation form with 1 -2 rated as lowest performance; 3 as borderline, 4 as acceptable performance and 5 as excellent performance.

Results
Results were analysed to determine the total mean scores o f the tw o groups, to determine variations in their performance by the different levels o f training o f the tw o groups; to com pare sim ilarities/ v ariatio n in perfo rm an ce o f the tw o groups between similar levels and lastly to determine variation in performance by comparing the two approaches.and traditional approach group.Marked differences were show n betw een the scores of the lower and higher levels of training with the first and second year levels scoring low er than their senior counterparts.The mean scores for the traditional 4th years w ere 29,3 w ith a standard deviation of 7,1 while the PBL 4th years were 30,05 w ith a standard deviation of 6,3 (see table 3).

Performance by different levels of the same group
Differences among the three levels of tra in in g w ith in sam e g ro u p s w ere identified.In the Traditional learning group, the performances of the second years were lower than that of the 4th years with a mean difference o f 6.8.The same pattern was observed in the PBL groups with a mean difference o f 5,3 between the second and fourth year students.When the same levels of the two groups were c o m p a re d , s lig h t d iffe re n c e s w ere identified.Between the 4th year levels the difference in their performance was 1.2 while in the 2nd levels it was 2.2.From these findings, it is evident that as the lev e ls o f study in c re a se , a m arked im provem ent in the stud en ts' clinical reasoning occurs.

Mean scores in various phases of Triple Jump Exercise (TJE)
Interpretation of performances of the two groups on the 4 phases of the TJE was m ade p ossible by sp littin g the total scores of clinical reasoning according to the 9 evaluation items in the evaluation form as indicated in table 4.
Levels o f study w ithin and betw een g ro u p s d is p la y e d no c o n s p ic u o u s variability by mean scores in the various items.A mean difference of 0.2 was found in these performance scores and this was not sufficiently significant to establish the e x is te n c e o f d iffe re n c e s in perform ance.Again h igher levels of study revealed better performances than the lower levels in all items contained in the instrument.All the levels 1st, 2nd and 4th performed poorly in the amount of data collected (le ss th an 80% ).A c c o rd in g to the instrum ent 80% o f d ata co llected is adequate to initiate intervention for the problem situation.
To substantiate this descriptive statistics and to d e te rm in e th e e ffe c t o f the in d e p e n d e n t v a ria b le (c u rric u la r approach) the d ep endent variable (clinical reasoning), two factor analysis of variance and interaction tests were employed usiifg total mean scores of both groups.The question to be answ ered was w hether differences in the scores were due to the curricular approaches u se d , o r w h e th e r it w as o n ly the differences in the levels of training that made the difference or whether it was both.
R esults revealed that neither approach used nor the levels of training had a significant effect on the s u b je c ts ' c lin ic a l reasoning scores with p= 0,21 for TDL and 0 ,8 PBL The levels o f study w ere the factors that had a significant effect on the scores at p = 0.0001 (See Table 5).According to the results both hypotheses one and two were rejected.
A p o st-A N O V A te s t, u sin g Turkey's m ethod was done to establish and substantiate the ANOVA results, by identifying where the significant differences amongst levels of stu d y w ere.T he re s u lts c o n firm e d significant differences among the lower levels and higher levels of study at a p value of 0.05.Between 4Ih year levels and 2nd year levels with low er confidence limits of 2.9 and upper confidence limit = 9.2, differences were observed (6.075 mean difference).Between 4'h year levels and 1 year levels with lower confidence lim its (1 2 .26 4 ), th e re w as a m ean difference o f 8.768.Between 2nd year levels and l sl year levels no significant difference was marked.

Discussion
Total scores of the two groups on clinical reasoning abilities provided a composite picture o f group perform ances in the clinical reasoning processes as measured by the Triple Jump exercise.Variations according to levels o f study in both groups were identified, with senior levels p erfo rm in g b e tte r than th e ir ju n io r counterparts.From these results, it can be deduced that as students progress throughout from first year to fourth year, their clinical reasoning abilities improve.Benner, cited in M aynard (1994:103), contends that this is due to exposure to clinical experiences.The 4lh years have more clinical exposure than the Is' or 2nd years and hence their higher performance.Kataoka & Saylor (1994:353) also support the importance of clinical experience (environment) an im portant com ponent in com petence developm ent.Sedlack (1997:14) also alluded to the im portance o f clinical en v iro n m en t to the d e v elo p m en t o f students' critical thinking skills.The results o f this study also refuted the conclusion that curriculum approach has an effect on clinical reasoning.In other w o rd s, th ere are o th e r fa c to rs th at influence the student's clinical reasoning ability rather than only the approach used.
The results show ed no co n sp icu o u s difference by approaches.The PBL group had been expected to perform better because o f the hypo-deductive model used in this ap p roach, alth o u g h the specific instrument was not familiar to them.

Limitations
The sampling technique used which was a non-probability technique lim it the representativeness o f the study sample and h en c e the g e n e ra lis a tio n s o f findings was weakened.The two research settin g s used w ere w ith in the sam e region and they m ight share sim ilar p ro b le m s, fo r an e x a m p le lim ite d resources that would impose a negative im pact on student learning and thus affect the results o f the study.Studies undertaken in other regions might reveal different findings.

Recommendations
The findings o f this study challenge nurse educators using the PBL approach to investigate the demonstrability o f the end re s u lts o f PB L .T h e fin d in g s challenge teaching and learning, for an ex am p le, the C ase B ased L earn in g approach.D eretchin (1999:64) also support the use of PBL alongside other approaches in a mixed curricular format.According to them this results in learners using deeper approaches to learning w h ich is la c k in g in th e PB L only approach and they show preference for active forms o f learning and the use of a variety of learning resources.
The C ase B ased L earning approach u tilizes case stu d ies as its teaching strategy and it stimulates ideas through complex problem-analysis of actual or hypothetical situations and provides a means of applying theoretical principles to practice.It is recommended as an effort to balance the limitations of both the PBL and the tra d itio n a l c o n te n t-b a s e d approach.It is also recom m ended for nurturing clinical reasoning skills based on the following characteristic features:

Conclusion
The findings o f this study contradict findings of H m elo's study (1998), cited by Huey (2001:72), w hich revealed that PB L s tu d e n ts p e rfo rm b e tte r th a n tra d itio n a l s tu d e n ts in g e n e ra tin g explanations that w ere m ore accurate, c o h e re n t an d c o m p r e h e n s iv e .T h e findings also rejected the hypothesis that the progression in the developm ent of clinical reasoning skills entry to exit will be higher for the PLB group than the Traditional group.Therefore the results o f this study lay a foundation for nurse educators to look beyond the approach used for teaching and learning and to begin to consider the context of learning in a broader sense than just the approach u se d .C lin ic a l s u p p o rt, th ro u g h accom paniment could still be regarded as having a positive influence on the d e v e lo p m e n t o f c lin ic a l re a so n in g .Clinical reasoning rem ains the crux of ex p ert p ractice and one o f the m ost dem anded skills for nurses to be able to deal w ith increasing com plexities o f

M
odels ex p lo re d w ere th e N ursing Process model, Outcomes model, Present state Testing model and the Hypotheticod ed u c tiv e m odels.T he m odel m ost a p p ro p ria te fo r the stu d y w as the H y p o th e tic o -d e d u c tiv e m odel.T his model emanated from empirical work of Elstein & Bordage in 1997, who analysed th e ju d g e m e n ts o f p h y s ic ia n s and discovered that their judgem ent was not intuitive but rather based on a cognitive strategy called hypothetico-deductive reasoning approach (Elstein & Bondage, 1997 :111).The model has the following stages: (a) Initial concept form ation Initial concept formation is activated by the p a tie n t e n c o u n te r.A d d itio n a l in fo rm a tio n is g a th e re d th ro u g h o b s e rv a tio n b a se d on a d d itio n a l information that the patient may present.During this stage, the practitioner selects pivotal findings which are used to bridge the gap from the presenting problem and the practitioner's extensive knowledge base.The information perceived during this encounter is continually analysed and assem bled into an initial concept through the reasoning process.(b) Hypotheses generation As the clinician assem bles the initial c o n c e p ts , a n u m b e r o f h y p o th e se s emerge.Through an inductive process of lateral thinking the practitioner thinks of possible conditions suggested by the patient's presenting problems.This stage provides a guideline as to what kinds of data to gather in o rd er to define the p a tie n t's problem s and to m anage it successfully.
Researchdesign T he stu d y u tiliz e d a c o m p a ra tiv e d e s c rip tiv e su rv ey .T h e c lin ic a l reasoning abilities o f the two groups of students were described in relation to the different curricular approaches.As one o f the o b je c tiv e s w as to d eterm in e progression levels of clinical reasoning abilities from entry level to exit level, cross-sectional data was used to examine difference in various levels of training.
the s c e n a rio w h ilst the re s e a rc h e rs to o k dow n n o te s o f the re sp o n se s v e rb a tim .A u d io tape re c o rd in g w as d o n e to complement the notes.ReliabilityThe set of items in the Triple Ju m p in stru m e n t has a certain degree o f internal c o n s is te n c y sin c e they measure critical attributes o f the p ro b le m so lv in g process, nam ely problem d e fin itio n , data c o lle c tio n , problem identification and initiation o f a nursing intervention.Measures to ensure inter rater reliability were made by using two examiners (researcher and an assistant) to rate the subjects independently during

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Table 2 : Application of the conceptual framework during data collection using the Triple Jump Exercise It
is about 2000 hours, M rs Zaza has been brought in the casualty departm ent where you are working.She complains of severe pains, looks pale, cold and has a splinted left fore arm.