Nurses often work in settings where strong clinical reasoning skills are required to anticipate, prevent, and react to patient care situations. These skills, which impact a nurse's ability to provide safe care, develop through education and experience. Illness scripts have been used to teach clinical reasoning in medical schools, but their use has not been explored in nursing education. This article describes student self-efficacy of learning after using illness scripts to teach clinical reasoning in an online pathophysiology and pharmacology course for RN to BSN students.
BACKGROUND
Clinical judgment, which is a type of clinical reasoning, consists of pattern recognition, similarity recognition, and gaining a sense of salience (Benner, Sutphen, Leonard, & Day, 2010). Illness scripts are a strategy to apply clinical judgment via narratives that provide a structure for clinicians to categorize data and develop pattern recognition. When a similar set of signs and symptoms is encountered, the information can be recalled quickly. This method helps students break down complex disease processes into easily remembered components and apply the information to other situations, reinforcing clinical reasoning each step along the way (Lee et al, 2010).
On the basis of social cognitive theory (Bandura, 1982), self-efficacy is a known interplay between self-referent thought, action, and effect. Self-perception of capabilities impacts motivation and behavior. Higher levels of self-efficacy lead to the application of greater cognitive effort, with higher resulting performance.
Taking off from social cognitive theory, Rowbotham and Schmitz (2013) developed the student self-efficacy scale (SSE scale) to evaluate nursing student self-efficacy of learning in a classroom environment. It is scored using a Likert scale with a range of 1 to 10 for each item (1 indicates "I can't do at all"; 10 indicates "Very sure I can do). The SSE scale has been subjected to content validation and reliability testing ([alpha] = .84).
INTERVENTION
Illness scripts were adapted for use in nursing, taking emphasis away from making a differential diagnosis to prioritizing patient care needs. Through case studies, students were taught to apply clinical reasoning systematically: a) identify relevant subjective and objective data; b) write an illness script for three probable illnesses, inclusive of epidemiology, time course, signs and symptoms, pathophysiology, and pharmacology; c) analyze the illness script, looking for differentiating features; d) prioritize care for the patient; and e) determine how to evaluate the effectiveness of care. By clustering relevant clinical features together and linking presenting signs and symptoms with the underlying cellular mechanisms, pattern recognition and expertise were developed (van Schaik, Flynn, van Wersch, Douglass, & Cann, 2005).
To further learning, students posted their illness scripts to the course discussion board and critiqued the work of others. As students analyzed the work of their peers, they used current literature as evidence to back up any contradictions among illness scripts. The discussion board provided a platform for a collegial exchange of ideas as students developed mastery of the content.
METHOD
Following institutional review board approval, informed consent was obtained from a convenience sample of students enrolled in an online pathophysiology and pharmacology course for RN to BSN students. Participation was anonymous, and participants were able to opt out at any time with no consequences. At the end of the course, a demographic survey, the SSE scale, and open-ended questions were administered to the students via Qualtrics. Data were analyzed using the Qualtrics Research Suite.
RESULTS
Of 29 students enrolled in the course, 23 consented to participate (n = 23). Participants ranged in age from 20 to 54; most students (86.96 percent) were women.
A high self-efficacy of learning was found over all SSE scale items (M = 8.94, SD = 0.24). Items that rated participants' confidence scored the highest, such as "If I try hard enough, I can obtain the academic goals I desire" (M = 9.39, SD = 0.72) and "I know that I can finish the assigned projects and earn the grade I want, even when others think I can't" (M = 9.30, SD = 0.88). In contrast, items that rated attitude and coping scored lowest, such as "I know that I can maintain a positive attitude toward this course even when tensions arise" (M = 8.52, SD = 1.41) and "I am convinced that I can develop creative ways to cope with the stress that may occur while taking this course" (M = 8.74, SD = 1.18).
Participants reported that illness scripts were an interesting approach to learning and encouraged critical thinking. The majority (73 percent) responded that illness scripts contributed the most to their learning. Positive remarks about the teaching strategy included "The illness scripts! They truly helped me learn more than I thought was possible. It was an enjoyable way to conquer tough material" and "The illness scripts were great learning tools. They were one of the most stimulating and rewarding assignments in the entire program."
Participants reported that quizzes and exams did not enhance their learning. Student comments included: "Reading the chapters was not enough to retain all of the information without applying it in some way" and "I have been in nursing 22 years, and I learned so much from this class. I honestly have nothing but positive feedback. It gave me confidence when I needed it most."
DISCUSSION
Innovative approaches, such as clinical rounds and concept mapping, focus on student engagement as a key factor for student success (Taylor & Littleton-Kearney, 2011). Active learning strategies, such as case studies and homework sets, improve student learning and understanding of concepts in pathophysiology courses (Van Horn, Hyde, Tesh, & Kautz, 2014). Each of these approaches uses a systematic organization of knowledge to develop clinical judgment and decision-making skills, similar to the structured approach of illness scripts.
Benner's call for transformation of nursing education urges faculty to seek out innovative, active learning methods (Benner et al., 2010). Adapting illness scripts to nursing education takes learning beyond knowledge and comprehension to application and analysis, mimicking the real-life work of nursing.
CONCLUSION
The use of illness scripts is common in medical education to enhance clinical reasoning and decision-making. Adapted for nursing education, illness scripts proved to be an effective, active learning strategy. This engaging strategy to learning is something faculty can use in many types of nursing courses.
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