Using ‘think aloud’ as a strategy for improving clinical reasoning in high fidelity case-based
simulation for undergraduate nursing students.
Pauline Calleja 1, Professor Robyn Nash 2, Professor Vivienne Tippett 3, Theresa Harvey 4, Lisa
Wirihana 5 & Dr Naomi Malouf 6
1
Simulation Coordinator/Lecturer, Faculty of Health, Queensland University of Technology, Brisbane,
Australia, 2Assistant Dean – Teaching and Learning, Faculty of Health, Queensland University of
Technology, Brisbane, Australia, 3Head of Paramedic Sciences, School of Clinical Sciences, Queensland
University of Technology, Brisbane, Australia, 4Subject Area Coordinator- Clinical/Lecturer, School of
Nursing, Queensland University of Technology, Brisbane, Australia, 5Subject Area CoordinatorCaboolture campus/Lecturer, Queensland University of Technology, Brisbane, Australia, 6Unit
Coordinator/Lecturer, School of Nursing, Queensland University of Technology, Brisbane, Australia.
Core 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.
Traditionally clinical placement has been relied upon to assist students to practise the application of
critical thinking and problem solving skills in ‘real world’ situations. However, regardless of the
settings in which students are placed, the uncertainty and poor predictability about the type and
quality of learning experiences that students will encounter has led to clinical placement being
described as “education by random opportunity” (LeFlore et al., 2007, p.170). Due to this issue many
schools are embracing simulation, in particular high-fidelity simulation, as a contemporary way of
improving the consistency and quality of students’ preparation for clinical practice (see for example
Pike and O'Donnell, 2010, Waxman, 2010).
The think aloud procedure is a process-oriented strategy that asks participants to verbalise their
thought processes and rationales for the types of situations or questions they are being asked to
work through. Process oriented strategies such as think aloud, emphasise the importance of
cognitive processing and cognitive development to the development of graduate capabilities for
professional practice. Importantly, think aloud is both a teaching tool and a potentially powerful
learning strategy for students. Think aloud has the potential to explicitly facilitate cognitive linkages
between Reflective Observation, Active Experimentation and Abstract Conceptualisation and, hence,
improve the quality of students’ experiential development of clinical reasoning within the context of
real-world simulation experiences.
One of this project’s aims was to explore the effectiveness of a ‘think aloud’ strategy for improving
third year nursing students’ development of clinical reasoning within a simulated learning context,
MEHODS: In semester 2 2011 at QUT, third year nursing students undertook high fidelity simulation.
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. 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 was obtained for
this project.
Methods to measure outcomes of the proposed strategy were approached from student and staff
perspectives. Focus groups were conducted with students from cohorts to explore their perceptions
regarding the simulation experience and particularly clinical reasoning. Focus groups were
conducted separately with simulation facilitators to explore perceptions of students’ clinical
reasoning during simulations. Focus groups were conducted by a research assistant not involved in
teaching nursing simulations or in any part of the third year nursing program.
Focus group data was transcribed to writing in real time using a stenographer. These data were
analysed using coding (Stewart, 1992) and procedures adapted from Silverman (Silverman, 2001)
and Miles and Huberman (Miles and Huberman, 2002). The focus groups were undertaken as soon
as possible after the simulations were completed, usually within 2 weeks.
RESULTS:
26 Students were involved in the intervention simulation cohort, 24 were in the control groups and
five facilitators ran these simulation. Some facilitators had both control and intervention groups.
Focus groups were held at times that suited participants. Seven students involved in the
intervention, 5 students involved in control groups and three facilitators were involved in the focus
groups.
Initial results of a qualitative analysis of student and facilitator reports on students’ performance in
managing patient conditions in these simulations revealed a number of themes. These themes
include Student Variation, Preparation, Confidence and Anxiety, Leadership, Teamwork,
Communication and Decision Making.
Student Variation: Students regardless of being in control or intervention groups showed significant
variation within each of the themes of ‘preparation’ and ‘confidence and anxiety’.
‘My think aloud group...the first time around they had a strong leader, they used
the strategy to think aloud brilliantly...two of them it came naturally, thinking
aloud and problem solving. The other half were not as strong and hesitated in
saying that and verbalising how they said it. The group that was not the think
aloud...clearly different.....they did not say anything and fluffed along unless
there was a good leader.’ (Facilitator)
Preparation: Subthemes in this theme included ‘knowledge’, ‘past experiences’ and ‘skills’.
Knowledge described three characteristics which included being prepared for simulation experiences
(students had access to specific preparatory materials prior to being involved in each simulation),
patient assessment tools that students had knowledge of, and previous knowledge that had been
applied in practice and confirmed when on clinical placement/other learning experiences. Students
felt that the experiences (regardless of the intervention) required them to draw upon their
knowledge base and apply it to the decision making rather than just ‘do it’.
‘it makes you think about – like not just give them a pill and make them better,
sort of thing. ..there are reason[s] why...it gives you more depth into the
condition I thought’ (Student, Control group)
When considering the intervention of ‘think aloud’ poor knowledge clearly decreased the ability to
use this intervention to support clinical reasoning. This was the theme area where the intervention
of think aloud seemed to have the most effect on what occurred within the simulation.
‘Knowledge is power, and the more you know, the better prepared you are…if
you are prepared you are in the best situation to provide care for your patient’
(Student, Intervention Group)
Past Experiences related to learning sessions where specific skills were demonstrated and broken
down for students and having an opportunity to practice these skills. Students discussed clinical
placement experiences as consolidating or making the skills and knowledge real and applicable to
how to “do” patient assessment and care and this impacted on how well they were able to apply
their learning within the simulation setting. Some students felt previous experiences in high fidelity
simulations were helpful in being prepared for the roles they would play in real practice. If students
had been involved in making care decisions before this also positively impacted on them being able
to undertake this in the simulation environment where there was no clinical teacher directing their
practice, just the patient responding to them.
Skills related to students remembering practising clinical psychomotor skills or communication skills
either at university or in real clinical practice. Those who could not remember anything related to a
particular skill required for the patient in the simulation felt unprepared and were observed to be
‘stuck’ in being able to care for the patient (e.g. check nasogastric tube placement, or set up and
administer a STAT IV fluid bolus). Those students who remembered skills often identified knowing
‘sort of’ what to do, but not feeling confident. This was contrasted to students who had experienced
and practiced the skill in their last clinical placement; these students felt confident and were willing
to try to complete the skill or guide and give advice to other students to do it.
Students felt the context of the simulation was a factor that impacted on performance. For example
some students identified not having had an acute clinical placement yet so they had no idea what a
nurse ‘did’ in that context. All simulation experiences were set in in acute care contexts. Context
related to the reality of the simulation, with students expressing surprise at how realistic the
situation and environment was and how this would impact on future experiences.
‘because now I know that it’s going to be like real, the patient is talking. Next
time I will read a little bit more about the scenario’ (Student, Intervention group)
Only a few students discussed not being able to forget that the manikin was not a real patient once
they became involved in the situation.
Confidence and Anxiety had five specific characteristic factors including; preparation, responding,
performing, being watched, and applying to current situation. Students reported polarities in some
clearly attending the simulation without any preparation and others who due to their anxiety
undertaking extensive preparation.
Responding related to responding to the patient (the manikin) and to other team members. Some
students were shocked to have the manikin respond in real time and in specific context to what was
happening. Some students were able to appreciate this as making the situation real and others were
unable to concentrate and became flustered in making decisions and giving care.
‘This dummy is talking back; it is not just quiet… We procrastinated in the wrong
direction but we have to think again and prioritise. I felt doing it, if I was to do
the simulation again, now that I have got a bit of experience, knowing what to
expect, I think I would perform a little bit better than the first time.’ (Student,
Intervention group)
Performing related to some students feeling like the situation was a good opportunity to show what
they could do, while others felt the pressure of performing increased their anxiety to levels where
they did not perform as they expected. Practising more seemed to most students be an answer to
reducing anxiety and getting used to performing like a Registered Nurse.
‘... The more you do, the better you become at it. It is just like prac because the
dummy talks back …It helps to reduce anxiety, helps you to think out more aloud,
critical thinking. You have to think outside the square…and bring it back
together, form that story and make decisions based on that.’ (Student,
Intervention group)
Being watched was an unsettling sensation for students as some of them commented on this
impacting on how they actually were able to perform as a result.
The combination of student variation, student’s levels of preparation and confidence and anxiety all
seemed to impact on the next three themes of leadership, teamwork and communication. The
intervention of ‘think aloud’ seemed to have the most effect in the areas of teamwork and
communication.
Leadership was important in having ‘things happen’, this included all areas of the situation from
patient assessment, communication and rapport building, to responding to the patient cues and care
planning and intervention, along with deciding if other support was needed from external health
team members (Doctor, MET team). It was evident that most students had not taken a leadership
role in clinical care and many were anxious about this.
Teamwork included the characteristics of group dynamics, roles delegated or taken, experience with
teamwork and trust in others/knowing others in their team. Communication quality with the patient
and within the team was an apparent factor in how well teams were able to manage a patient
situation and the care planning and implementation.
Decision Making was the final theme, with most students being anxious about making the right
decisions, and felt that the many themes and factors discussed earlier impacted on decisions made
and the impact these decisions had on patients and their outcomes.
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. Think aloud was a strategy that we implemented and found that this strategy
impacted on knowledge and knowledge sharing, and this in turn caused better teamwork, more
communication but not necessarily increased quality in these aspects. Lessons learned revolve
around teaching students more explicitly about think aloud as a strategy to prompt communication
and knowledge sharing and modelling this in our teaching styles of critical thinking and clinical
reasoning.
References
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