Clinical reasoning is a situated, practice-based form of reasoning requiring background scientific knowledge applied to a particular patient using the clinical evidence presented (Benner et al, 2008). It is an essential component of professional practice and enables health professionals to analyse information relevant to patient care. Modern healthcare involves complex decision-making processes, often under conditions of uncertainty (Simmons et al, 2003), so practitioners need strong clinical reasoning skills.
Patient safety is paramount to healthcare providers (Berwick, 2013); however, preventable harm affects nearly one in 20 patients within health services in the UK (Panagioti et al, 2017). In the 2017–2018 financial year, the NHS paid out more than £1.63 billion in damages to clinical negligence claimants (NHS Resolution, 2018). Improving clinical reasoning may strengthen professional practice by increasing the accuracy of decisions and therefore improve patient outcomes (Simmons et al, 2003).
Clinical reasoning is a difficult skill for students to develop, partly because it is not possible to guarantee they will become aware of it and develop it while in practice. Professional developments within the past few years have established a supportive preceptorship programme within NHS trusts for new paramedic registrants (NHS Staff Council, 2016); enhancing activities to develop these crucial skills in a preregistrant programme should be prioritised to enhance the abilities of students and therefore new registrants (Quality Assurance Agency for Higher Education, 2016; Health and Care Professions Council, 2017). A better understanding of the reasoning processes used during clinical reasoning may help health professionals with less experience to develop processes for their own clinical reasoning (Simmons et al, 2003).
The higher education environment for health science students is in a period of significant transformation, with changes such as the removal of the bursary, the introduction and the first awards of the Teaching Excellence and Student Outcomes Framework (TEF), the recently established Office for Students as well as the effects of Brexit (Council of Deans, 2018). The provision of a high-quality academic experience for students, with significance placed upon student outcomes and learning, remains central within this changing environment (OfS, 2018). The University of Surrey was awarded gold in 2017's TEF, in particular for innovative provision and digital resources that enhance learning and encourage a high degree of commitment (Bhardwa, 2019). Future iterations of the TEF will be programme-specific and therefore there is a need to evidence the student experience.
How can we improve the teaching of clinical reasoning?
Upon successful completion of their degree, students will register and operate remotely as autonomous practitioners. While the curriculum emphasises that an awareness of decision-making processes is necessary, applying these in a safe, non-practice environment is difficult and problematic.
Clinical reasoning is complex to teach (Linn et al, 2012), with theory often being difficult to apply explicitly within practice because of unpredictable exposure and practicalities, combined with a lack of time to reflect upon any opportunities. While recent professional developments have established a supportive preceptorship programme for new paramedic registrants, developing these crucial skills in a preregistration programme should improve the abilities of students.
‘Think aloud’ is a technique to collect verbal data about an individual's cognitive processes during a specific task (Simmons et al, 2003). Following a ‘think aloud’ case study presented by veterinary school colleagues and tutors (Trace and Tisdall, 2018), this approach was adapted by the paramedic science tutors to enhance and develop the skills required by health science students.
In the classroom, think aloud provides opportunities for students to explore gaps in knowledge, develop a socially constructed understanding of concepts and think more deeply about those concepts (Bergman and Sams, 2012) in a learner-centred model. Think aloud has been used in a variety of practice areas and disciplines but had not previously been applied to UK paramedic education. However, it has been applied within a UK higher education model and had a positive evaluation (Trace and Tisdall, 2018).
Aim
This study aimed to evaluate a teaching tool, established in other disciplines, for developing students' clinical reasoning skills. It had three objectives: to seek the opinions and experiences of students undertaking this learning activity and their level of enjoyment; to make a qualitative evaluation to ascertain student belief of validity and awareness of the skills they wish to develop; and to determine its feasibility as an ongoing method used to improve the teaching of clinical reasoning skills. It also explored the potential for embedding similar exercises throughout the programme to assist students to apply theoretical components of the course to clinical situations.
Exercise methodology and evaluation
The learning activity was undertaken with 39 third-year paramedic science students in the induction week for their compulsory, final-year practice module.
Students were briefed about details of the exercise at the start of the session, including its aims and objectives. For this study, participants spoke their thought processes out loud while working through a clinical case. A written case study allows researchers to present essential elements of the case in the order they choose (most likely to reflect best practice) and therefore closely simulates an actual patient scenario with information revealed in segments (Fonteyn et al, 1993). Recordings of these cases can then be listened back to, which allows students to reflect upon their approach to clinical reasoning.
Participation in the ‘think aloud’ exercise was compulsory. Upon completion of the activity, students were invited to participate voluntarily in an online semi-structured questionnaire evaluating the exercise. There was no requirement to complete the questionnaire and students were free to leave at the end of the teaching session. Of the 39 students, 32 agreed to take part. Completion of the evaluation was taken as provision of informed consent. Students were able to contact the lead researcher after completion if they wished to withdraw their consent, though none did.
The questionnaire responses, including free-text answers, were collated and analysed in order for the teaching tool and its application to clinical decision-making to be evaluated. The questionnaire covered students' awareness of their clinical reasoning processes, and how they believed the activity affected this.
The research was approved by the university's ethics committee (University of Surrey, 2018).
Results
The questionnaire was answered by 32 of the 39 student paramedics, although not all individuals answered every question. The analysis focused on: whether the students had enjoyed the activity and how easy it had been to navigate; the systematic approach required; the potential benefits of talking aloud; influences on decision-making; how the activity could be implemented; and what, if anything, could be improved. Verbatim quotations are given with unique participant identifiers.
When asked about their enjoyment of the exercise, only two students had not enjoyed it, with both saying they did not feel comfortable speaking out loud to themselves with other people in the room. Of those who did enjoy it, the task was seen as a novel teaching approach:
| Age range (years) | Female | Male |
|---|---|---|
| 18–24 | 15 | 6 |
| 25–34 | 7 | 3 |
| 35–44 | 0 | 0 |
| 45–54 | 1 | 0 |
| Total | 23 | 9 |
‘[It was a] fun, useful way to challenge clinical decision-making and knowledge.’ (Participant 31)
In particular, the logical, systematic approach required was found to be useful, especially when students were able to see only certain information (such as medical history, observations, clinical assessment of systems and clinical predictive scores) at a time:
‘It allowed me to apply a very systematic approach and explore all angles of assessment.’ (Participant 14)
In terms of how the activity was presented, the format was seen as useful, and students acknowledged that this was an accurate reflection of what they were experiencing in their practice:
‘It really helped being able to navigate back to things previously said as in real life you would be able to go back through paperwork, if you have these things written down.’ (Participant 24)
Nine students commented on the benefits they perceived from having to talk aloud, with particular reference to the structural approach created. This is in line with historical opinion and teachings within the field and medical consultation models (Croskerry and Nimmo, 2011; Brown et al, 2016; 2019).
Verbalising my thought process helped organise my thoughts and use a more structural approach.’ (Participant 17)
The process of talking out loud was useful for a number of students as a way of ensuring their thought processes were clear and potentially usable by others. If assumptions were made, these could be identified and addressed as students were aware they were talking out loud and being recorded:
‘Talking out loud was a good way to make sure the thought process made some sense because it was like I was trying to explain it to someone else.’ (Participant 28)
‘Kept correcting self as I made assumptions because I was talking out loud/being recorded.’ (Participant 31)
Implementation into teaching
When asked how this technique could be developed for wider use within the curriculum, a variety of clinical presentations were suggested. ‘Homework’ or consistent practice were mentioned, perhaps in the form of a case to work on at home (participants 1 and 12), after a lecture (participant 10) or done in other ways:
‘At the end of a simulation scenario, the exercise could be used as a way of putting into practice what we have learned in a real-life setting.’ (Participant 11)
‘I would like a session with lots of clinical scenarios, 10 different ones that are “serious” jobs that we may not have been to in practice’. (Participant 21).
Timings are a consideration for this format of activity and how it should be employed to achieve optimal benefit. The students were about to enter the final consolidated period of practice placement:
‘It should be implemented regularly to help improve our confidence going back to placement as it enables us to feel more confident ruling out most other differential diagnoses.’ (Participant 14)
Influences on decision-making
Many students commented on how the process of talking aloud had enabled them to question their decisions, allowing them to see where they were potentially forming early conclusions that were not necessarily correct.
‘Made me consider differential diagnosis rather than having one idea and sticking with it, which I sometimes do when I think I'm right. Challenged my thought process.’ (Participant 6)
‘Talking through findings and referring to guidelines helped my understanding and differentials. Allowed me to explore all options as if I were with a crew.’ (Participant 19)
‘It put me in the position as the sole decision maker using the cues presented. This made me think more than I would in practice where others have an input. This allowed me to explore my clinical reasoning and thought processes.’ (Participant 5)
This paradigm is interesting considering the dynamic of supernumerary placements, where the students will have had an ever-present safety net and an absence of overall responsibility; removal of these meant they could no longer rely on other clinicians.
While students mainly enjoyed the exercise, with six saying they would change nothing, others put forward a number of suggestions. The opportunity to debrief afterwards was suggested by three students:
‘A debrief discussion afterwards to determine what the answer was and the correct management plan.’ (Participant 12)
Other students would have preferred a different environment or the opportunity to complete it at home:
‘I think it would have been better doing it individually without loads of people around as it was quite distracting.’ (Participant 29)
Regarding the clinical information, students disagreed as to whether too little or too much had been provided, and mentioned the effects this may have had:
‘While I appreciate not everything could be accounted for, [I] would've like[d] things like [a] full set of obs as an option, possibly OPQRST [onset, provocation, quality, radiation, severity and time] pain assessment.’ (Participant 10)
‘Maybe remove some of the available tests “Wells’ criteria” etc as they can influence thinking. I never would have thought of Wells’ criteria if it had not been a choice.’ (Participant 6)
Discussion and conclusion
Clinical reasoning is key to good practice, as strategies for preventing and reducing diagnostic incidents have the potential to improve patient safety in healthcare (Panagioti et al, 2017). However, teaching it presents a challenge to both students and teachers.
The think aloud process makes the clinical reasoning processes more explicit, enabling inexperienced clinicians to learn from the processes (Pinnock et al, 2015). The exercise allowed students to critically engage with their own methods and processes of working, while explicitly considering the theoretical context of a clinical situation within a safe setting.
Key aspects highlighted were opportunities to respond to information gathered throughout the exercise at students' own speed, and with their own prioritisation, rather than anticipating and responding to the perceived will of mentors or staff in practice. Students noted that it made them more aware of assumptions they made throughout their patient encounters, and provided opportunities to explore and consider information that was not immediately apparent.
The participants disagreed over whether the information provided in the exercise was satisfactory in quantity and content. The flexible nature of the format could allow the exercise to cover different information and clinical settings, and the difficulty of an activity to be adjusted to the level of student; for example, information from radiographs and blood gases would be appropriate for hospital-based clinicians but not necessarily acute out-of-hospital practitioners. Consideration could also be given to omitting certain elements to challenge experienced clinicians undertaking continuing professional development.
Because this study focused on the reflective process of this learning activity with the opportunity for self-appraisal later on, there was no scope in this initial evaluation to implement a structured debrief. However, if think aloud is expanded to related modules, opportunities to discuss the case, confounding factors and differing opinions and treatment options presented by students should be incorporated alongside the previously identified reflective mechanisms, thus providing further internal and external feedback to learners.
Having to be self-reliant throughout the exercise promotes students' independence of thought, which is expected of autonomous practitioners on qualification and registration, and could assist with transition into practice.
The results of this case study indicate that the teaching method has the potential to be effective in developing clinical reasoning skills in student paramedic education. It could complement established teaching strategies, such as core lectures, seminars and supervised practice. This could inform future curricula design and teaching strategy: if its use were expanded throughout the course (as requested by a number of participants), it could reinforce and enhance desired student attributes, including self-awareness and appraisal of individual decision-making. It could also contribute to lifelong learning principles and holistic development of healthcare practitioners. This is in line with evidence and conclusions from evaluations in other practice settings (Trace and Tisdall, 2018).
If these can be attained, the think aloud learning method has the potential to improve patient safety through increased efficacy and safe working by registrant paramedics on graduating from university.