NUR5194 Module 3 literature review and project proposal example

One Patient, Four Questions: A Literature Review and Proposal for a Clinical Judgment Structure in Post-Conference, Tested in Four of Eight Clinical Groups

Student Name

American College of Education

NUR5194: Capstone Practicum for Role of the Nurse Educator

Module 3 Assignment

Instructor Name

October 10, 2028

The Problem in Brief

The needs assessment found that in the course's clinical post-conferences, 71% of instructors' questions asked students to remember or understand, only 11% asked them to analyze or evaluate, students spoke for about 38% of the time, and students' lowest clinical evaluation scores were on interpreting patient data. Instructors, most of them part-time, had no preparation for leading post-conference and asked for a structure. One instructor already led conferences differently, with one patient discussed in depth and questions posed to the group, and her students spoke more and scored higher on interpretation.

What the Literature Shows

Post-conference practice. The pattern found in the course is not unusual. Observing post-conferences led by ten faculty members, Hsu (2007) found that most faculty questions stayed at the bottom of the cognitive scale and that the talk centered on tasks, organized around assignments, reports and skills rather than reasoning. The literature on post-conference consists mainly of descriptive studies and reports of teaching strategies; controlled evaluations are rare.

Guided questions. Several programs have tried to standardize post-conference with planned questions. Harvey (2015) described a second-year clinical course in which open-ended guided questions linking classroom content to clinical experience were built into every weekly post-conference, and reported that the questions helped instructors facilitate discussion and identify gaps in students' thinking, while stressing that instructors needed preparation to use them well. The report is descriptive and did not measure student outcomes, but it supports the feasibility of a shared question structure for part-time instructors.

Structured reflection. The strongest evidence for structured, theory-based reflection comes from simulation debriefing rather than post-conference. In a quasi-experimental study, Dreifuerst (2012) found that students debriefed with Debriefing for Meaningful Learning, a structured method that guides teachers and students through reflection, showed greater gains in clinical reasoning and rated the debriefing as higher in quality than students who received customary debriefing. Post-conference and debriefing share a purpose, turning experience into learning through guided reflection, so the finding is relevant, although a clinical day is less controlled than a simulation.

A shared model of clinical judgment. Drawing on decades of research into how nurses reason, Tanner (2006) set out a model in which a nurse notices what matters, makes sense of it, acts and then reflects on what happened. Lasater (2007) developed a rubric describing development across those phases and found that students' interpreting was the phase that lagged in early development. The model gives post-conference a structure that matches what the course's evaluation tool measures and what students struggle with.

The Gap and the Guiding Theory

The literature supports structured, theory-based reflection and suggests that guided questions can help part-time instructors, but it offers little evidence on whether restructuring clinical post-conference changes the level of discussion or students' interpretation of patient data. This project cannot close that gap, but it can add a small, carefully measured local test. The project borrows a structure that has worked in simulation debriefing and asks whether it works on an ordinary Tuesday afternoon after eight hours on a medical-surgical unit.

Tanner's clinical judgment model is the guiding theory. It supplies the structure of the questions, it names the phase students most need to practice and it gives instructors and students a shared language that the rest of the program's curriculum is adopting.

The Project

There are two components. First comes a structure for post-conference called One Patient, Four Questions. Each conference begins with one student presenting one patient in five minutes: the situation, the key findings and one thing the student was unsure about. The group then works through four questions for about 25 minutes, one for each phase of Tanner's model: what did you notice, and what else should we have looked for; what could explain these findings, and which explanation is most likely; what would you do, and what would you watch for overnight; and looking back, what would you do differently tomorrow. The instructor poses the questions to the whole group, not only the presenter, and waits for several answers before responding. The final ten minutes are a what-if: the instructor changes one finding, such as a falling blood pressure, and the group reasons through the new situation. Each student ends by writing one thing they will look for on their next clinical day. A pocket card with the four questions and sample follow-up prompts supports instructors.

The second part is instructor preparation: a 90-minute workshop co-led by the author and the instructor whose conferences already followed this pattern, with a video example, practice leading a conference with colleagues playing students and a discussion of how to handle silence and wrong answers.

Objectives, Implementation and Evaluation

The project will be implemented in four of the eight clinical groups, those whose instructors volunteered, from week seven to week twelve, while the other four continue their usual approach; if the evaluation is favorable, all groups will adopt it the following semester. Its objectives are that, in the intervention groups by week twelve, at least 35% of instructors' questions will be at the analyze level or above, up from 11%; students will speak for at least 55% of conference time, up from 38%; and the mean change from midterm to final on the clinical evaluation item for interpreting patient data will be larger than in the comparison groups. A secondary objective is that at least 70% of students in the intervention groups will rate post-conference as usually or always useful.

Evaluation will repeat the needs assessment's methods: two observed conferences per group in weeks eleven and twelve, coded by the same method and with the same reliability check, the same student survey and the same evaluation data. Because groups were not randomly assigned and instructors who volunteered may differ from those who did not, the comparison will be interpreted cautiously. The university's review board confirmed that the project, as an evaluation of an educational practice using de-identified data, does not require full review.

Anticipated Barriers

Three barriers are likely, and the plan responds to each. First, instructors may revert to familiar patterns when students are tired or the unit has been difficult. The pocket card and a brief check-in with the author after each of the first three conferences will help instructors keep to the structure, and the author will co-lead the first conference in each intervention group. Second, students used to reporting on every patient may feel that only one patient is discussed, and that their own experience is ignored. The final written reflection and the rotation of the presenting student ensure that each student presents at least once in the six weeks, and the what-if question invites every student to reason, not only the presenter. Third, silence. Higher-level questions produce longer pauses than recall questions, and instructors who are uncomfortable with silence tend to answer their own questions. The workshop will practice waiting, with a simple rule of counting to ten before rephrasing, and will encourage instructors to ask students to discuss in pairs for a minute before answering aloud. The barriers will be tracked through the author's observation notes and the instructors' weekly comments, and adjustments made during implementation will be reported in Module 4.

References

Dreifuerst, K. T. (2012). Using debriefing for meaningful learning to foster development of clinical reasoning in simulation. Journal of Nursing Education, 51(6), 326-333. https://doi.org/10.3928/01484834-20120409-02

Harvey, G. (2015). Connecting theory to practice: Using guided questions to standardize clinical postconference. Journal of Nursing Education, 54(11), 655-658. https://doi.org/10.3928/01484834-20151016-08

Hsu, L.-L. (2007). Conducting clinical post-conference in clinical teaching: A qualitative study. Journal of Clinical Nursing, 16(8), 1525-1533. https://doi.org/10.1111/j.1365-2702.2006.01751.x

Lasater, K. (2007). Clinical judgment development: Using simulation to create an assessment rubric. Journal of Nursing Education, 46(11), 496-503. https://doi.org/10.3928/01484834-20071101-04

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. https://doi.org/10.3928/01484834-20060601-04