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Want Your Graduates to Succeed? Teach Them to Think!

Caputi, Linda, J.; Kavanagh, Joan, M.

doi: 10.1097/01.NEP.0000000000000271
DEPARTMENTS: Guest Editorial

About the Authors Linda J. Caputi, EdD, RN, CNE, ANEF, a nursing education consultant and author, is editor of the Nursing Education Perspectives Innovation Center. Joan M. Kavanagh, MSN, RN, NEA-BC, is the associate chief nurse of nursing education and professional development, Cleveland Clinic Foundation, Cleveland, Ohio. For more information, contact Linda J. Caputi at

The authors declare no conflict of interest.





The delivery of safe, highly reliable health care is compromised as many new graduate registered nurses (NGRNs) enter clinical roles underprepared for the complex demands of professional practice (Benner, Sutphen, Leonard, & Day, 2010 ; Fero, Witsberger, Wesmiller, Zullo, & Hoffman, 2009). Formidable challenges, including an explosion of knowledge, intensify the need to produce graduates able to succeed in the demanding world of health care as thinkers and knowledge workers.

The amount of data produced now exceeds our ability to assimilate it. In the 1950s, when Marlene Kramer, renowned author of Reality Shock: Why Nurses Leave Nursing (Kramer, 1974), received an undergraduate degree in nursing, it was estimated that the doubling time of medical knowledge was about 50 years. By 2010, medical knowledge doubled approximately every 3.5 years. And by 2020, medical knowledge is projected to double in just 73 days (Densen, 2011). In the name of patient safety and new-graduate success, response to the exigencies of exploding data and content-laden curricula is already overdue.

The explosion of knowledge, evolving interprofessional approaches to the delivery of care, and advances in the science of learning and technology may appear to be perennial concerns, but today, these formidable challenges present and morph at the speed of light. Not surprisingly, in the midst of this information and technology “big bang,” the demand and the necessity to produce graduates able to succeed in the real world of rapidly changing health care practice have never been greater. How then, amidst rising consumerism and demands for accountability, can higher education adequately prepare the knowledge worker of the future (Ancheta, 2013 ; Hendricks, Taylor, Walker, & Welch, 2016)?

Building on Kramer’s seminal work, Duchscher (2009) used the term transition shock to describe the new-graduate transition as a dramatic role evolution from the protected education environment to professional practice. Rising national first-year turnover rates of NGRNs represent the well-documented stress of transition to practice and ultimately impact the quality of patient care. Today, transition shock is juxtaposed to the dramatically changing health care landscape, a world of accelerated knowledge creation, increased patient acuity, and decreased length of stay.

Without explicit guidance on thinking applied to classroom activities and clinical practice, the nursing student is left attempting to copy what faculty role model without understanding the underlying thinking. But role modeling is no longer enough to close the preparation-practice gap. A specific, detailed plan, which provides a foundation in the first semester, is then applied throughout the program with faculty using thoughtful listening.

The major issue impacting graduate success is the inability to think at the level required for entry into practice positions. Kavanagh and Szweda (2017) reported on a number of research studies that assessed clinical reasoning. In 2005, 35 percent of NGRNs were found to be in the acceptable range. That percentage decreased to 23 percent between 2012 and 2015.

Critical thinking and clinical reasoning are known to have a significantly positive correlation with nursing competence (Chang, Chang, Kuo, Yang, & Chou, 2011). Because the quality of patient care can be linked to the competent performance of nurses (Institute of Medicine [IOM], 2011), it is essential to narrow the preparation-practice gap by identifying ways to help NGRNs successfully transition from the academic world to the world of professional practice. The IOM’s focus on education report (IOM, 2010, p. 1) admonishes that “nursing education must be fundamentally improved both before and after nurses receive their licenses.”

This is where nursing education and staff development educators must work together. Academic nurse educators must develop a program-wide approach to teaching clinical reasoning. The old approach, where all faculty describe what they each do to teach thinking, no longer works. There must be a planned approach where the components of clinical reasoning are taught. Faculty must unpack clinical reasoning by using the four steps of Tanner's clinical judgment model (Tanner, 2006), augmented by explicitly teaching the thinking skills and strategies used in each step (Caputi, 2018).

Without explicit guidance on thinking applied to classroom activities and clinical practice, the nursing student is left attempting to copy what faculty role model without understanding the underlying thinking. But role modeling is no longer enough to close the preparation-practice gap. The actual process of how nurses think is taught in the first semester. A specific, detailed plan, which provides a foundation in the first semester, is then applied throughout the program (Caputi, 2016, 2018), with faculty using thoughtful listening to help students learn to think deeply and critically in any setting (Forneris & Fey, 2017).

Academic nurse educators and staff development educators must work collaboratively to discuss the manner in which clinical reasoning is taught and applied in nursing courses. Nursing students must be able to spend time during their clinical practicum days engaged in thinking, rather than spending the majority of time repetitively engaging in lower level nursing tasks. Staff development educators will then build upon this thinking when the nursing students join their organizations as NGRNs.

The key to new-graduate success and improving patient outcomes might very well lie in the way we teach students to think — something to think about.

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