Implementation and Evaluation of the Post-Practicum Oral Clinical Reasoning Exam

  • Tracy Levett-JonesEmail author
  • Helen Courtney-Pratt
  • Natalie Govind
Part of the Professional and Practice-based Learning book series (PPBL, volume 25)


Nurses with effective clinical reasoning skills have a positive impact on patient outcomes. For this reason it is imperative that students understand and are able to demonstrate application of the clinical reasoning process. While clinical reasoning is often taught and assessed in preparation for clinical placements, a post-practicum assessment can help to identify if and to what extent students’ clinical experiences influence their learning. The aim of this chapter is to provide a detailed overview of the development of a post-practicum clinical reasoning exam, guidelines for educators interested in adopting this novel approach, and results from the initial evaluation of the exam.

The post-practicum clinical reasoning exam for nursing students was conducted in the following manner: Students were provided with a verbal clinical handover and the healthcare records of four patients. In the individual face-to-face oral exam that followed, students were required to describe how they would prioritise, plan and manage the care of the four patients using the clinical reasoning cycle as their organising framework. The exam was marked by a trained staff member, and immediate summative feedback was provided. On completion of the oral exam students were invited to complete a short evaluation survey with closed and open-ended questions. Quantitative data was statistically analysed and qualitative data was thematically analysed. There were 471 students enrolled in the clinical course; of these, 181 participated giving a response rate of 38%. The mean satisfaction score was 3.03 out of a maximum of 5 indicating a moderate level of satisfaction with the oral exam. Three themes emerged from qualitative analysis: ‘Better than written assessment items’, ‘Authenticity of the approach’ and ‘The need for better preparation’.


  1. Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. JAMA, 290(12), 1617–1620.CrossRefGoogle Scholar
  2. Bucknall, T. (2000). Critical care nurses decision-making activities in the natural clinical setting. Journal of Clinical Nursing, 9(1), 25–36.CrossRefGoogle Scholar
  3. Cioffi, J., Salter, C., Wilkes, L., Vonu-boriceanu, O., & Scott, J. (2006). Clinicians responses to abnormal vital signs in an emergency department. Australian Critical Care, 19(2), 66–72.CrossRefGoogle Scholar
  4. del Bueno, D. (2005). A crisis in critical thinking. Nursing Education Perspectives, 26(5), 278–283.Google Scholar
  5. Ericsson, K., Krampe, R., & Tesch-Römer, C. (1993). The role of deliberate practice in the acquisition of expert performance. Psychological Review, 100, 363–406.CrossRefGoogle Scholar
  6. Fonteyn, M. E., & Ritter, B. J. (2008). Clinical reasoning in nursing. In D. J. Higgs, M. A. Jones, S. Loftus, & N. Christensen (Eds.), Clinical reasoning in the health professions (3rd ed., pp. 235–244). Oxford, UK: Butterworth-Heinemann.Google Scholar
  7. Forsberg, E., Ziegert, K., Hult, H., & Fors, U. (2014). Clinical reasoning in nursing, a think-aloud study using virtual patients - a base for an innovative assessment. Nurse Education Today, 34(4), 538–542.CrossRefGoogle Scholar
  8. Hoffman, K., Dempsey, J., Levett-Jones, T., Noble, D., Hickey, N., Jeong, S., et al. (2010). The design and implementation of an interactive computerised decision support framework (ICDSF) as a strategy to improve nursing students’ clinical reasoning skills. Nurse Education Today, 31(6), 587–594.CrossRefGoogle Scholar
  9. IBM Corp. (Released 2013). IBM SPSS Statistics for Windows, version 22.0. Armonk, NY: IBM Corp.Google Scholar
  10. Kirkpatrick, D. L. (2009). Implementing the four levels: A practical guide for effective evaluation of training programs: Easyread super large 24pt edition. Scholar
  11. Lapkin, S., Levett-Jones, T., Bellchambers, H., & Fernandez, R. (2010). The effectiveness of using human patient simulation manikins in the teaching of clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing, 6(6), e207–e222.CrossRefGoogle Scholar
  12. Levett-Jones, T. (2018). Clinical reasoning – What it is and why it matters. In T. Levett-Jones (Ed.), Clinical reasoning: Learning how to think like a nurse (2nd ed.). Frenchs Forrest, Australia: Pearson.Google Scholar
  13. Levett-Jones, T., Hoffman, K., Dempsey, Y., Jeong, S., Noble, D., Norton, C., et al. (2010). The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today, 30(6), 515–520.CrossRefGoogle Scholar
  14. Levett-Jones, T., McCoy, M., Lapkin, S., Noble, D., Hoffman, K., Dempsey, J., et al. (2011). The development and psychometric testing of the satisfaction with simulation experience scale. Nurse Education Today, 31(7), 705–710.CrossRefGoogle Scholar
  15. Pike, G. (1991). The effects of background, coursework, and involvement on students’ grades and satisfaction. Research in Higher Education, 32, 15–31.CrossRefGoogle Scholar
  16. Sandelowski, M., & Barroso, J. (2007). Handbook for synthesizing qualitative research. New York: Springer.Google Scholar
  17. Scheffer, B., & Rubenfeld, M. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, 39, 352–359.CrossRefGoogle Scholar
  18. Sinclair, P., Levett-Jones, T., Morris, A., Carter, B., Bennett, P., & Kable, A. (online 2017). High engagement, high quality: A guiding framework for developing empirically informed asynchronous e-learning programs for health professional educators. Nursing & Health Sciences, 19(1), 1–137.CrossRefGoogle Scholar
  19. Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgement in nursing. Journal of Nursing Education, 45(6), 204–211.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Tracy Levett-Jones
    • 1
    Email author
  • Helen Courtney-Pratt
    • 2
  • Natalie Govind
    • 1
  1. 1.University of Technology SydneySydneyAustralia
  2. 2.University of TasmaniaHobartAustralia

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