Improving clinical reasoning in nurse residents: Evaluation of a resident facilitator model in a nurse residency program

Clinical reasoning, a key component of knowledge development for new nurses, is a practicebased, situated form of reasoning that requires general case knowledge, basic scientific and evidence-based knowledge of patient care. Within Benner’s Novice to Expert framework, a quasi-experimental study with a matched pairs, pre-and post-test design, was conducted using a commercially available web-based instrument validated for measuring clinical reasoning in health care providers (Insight Assessment’s Health Science Reasoning Test-Numeracy). The study evaluated the nurse resident’s clinical reasoning skills in an established academic medical center’s nurse residency program. This followed the pilot of a four-session resident facilitation model using Socratic questioning, case studies, peer-discussion and self-reflection compared with the standard lecture model. No statistical significance between the intervention and control cohort was found on the overall clinical reasoning score (t=-.661 df (43), p=0.512> 0.05). However a statistically significant difference was noted on the sublevel category of explanation for the control group which could not be explained by this project (t=-2.043, df (43), p=0.047<0.05). This suggests the need for further studies to better understand the expected levels of clinical reasoning and impact of education delivery models within a nurse residency program

to improve new graduate transition to practice and patient care. The NRP curriculum requires specific competency development in critical thinking and leadership abilities. Participating hospitals use a 12-month customizable curriculum framework that emphasizes critical thinking and clinical reasoning skill development through new graduate peer group interactions and selfreflection. The NRPs framework curriculum aids in clinical knowledge acquisition Goode, McElroy, Bednash & Murray, 2013).
As critical thinking develops, the clinical reasoning ability of the nurse resident develops.
Clinical reasoning is defined as a situated, practice-based form of reasoning that requires the nurse resident to have a beginner knowledge level about general nursing skills and interventions and their application to a specific patient situation . Clinical reasoning can also be defined as the ability to sort through many details and develop a plan, change a plan or intervene appropriately within that plan (Pinnock & Welch, 2014).
Some transition to practice programs use Benner's Novice to Expert model (1984) for nursing knowledge and skill development ( Figure 1). In Benner's model, the advanced beginner or new graduate nurse comes with little ability to use concepts or context to care for the patient.
The model states that people gain skills by following steps, lists or rules and lack the ability to use concepts or judgement. Based on this model of knowledge and skill development, the graduate nurse needs both practice and coaching to develop clinical reasoning. The NRPs are structured to provide monthly classes for the nurse residents. These monthly classes can be facilitated by experienced nurses who have had specialized training, called 'resident facilitators' (see Appendix A for a description of NRP roles). The graduate nurses' knowledge and skill development may be improved, enhanced and supported in classes taught by experienced nurses.
This raises a transition to practice question. Does the use of a resident facilitator model in NRPs improve knowledge and skill development in the area of clinical reasoning?
Pinnock and Welch (2014) state a 'talk aloud' approach is an effective method for developing clinical reasoning. Nurse residents can be taught to use their didactic knowledge and when faced with a "what if' case based scenario, talk aloud and share thought process to develop their critical thinking or clinical reasoning skills. Case based scenarios can be used to assess the nurse resident's skill performance while the Socratic teaching method of "what if" questioning can stimulate critical thinking as the nurse develops clinical reasoning skills.

Theoretical Framework
This project used  framework that addresses the five stages of nursing skill and knowledge development: novice, advanced beginner, competent, proficient, expert ( Figure 1).
As an 'advanced beginner' the nurse resident's entry to the nursing profession needs to be supported and prescribed to create a successful transition to practice. The 2000 Vizient/AACN NRP model (www.vizient.com) supports a learning environment for building both knowledge and skills. During their first year of knowledge and skill development, nurse residents must achieve a level of clinical reasoning and judgement to detect when the patient exhibits clinical cues and then decide on an appropriate intervention, as they transition from 'advanced beginner' to 'competent' nurse. This is typically accomplished through experiential learning and evaluated using competency and skill assessments.  (Table 1). Three articles were systematic reviews of nurse residency programs (Table 2). In four articles the focus was NRP implementation (Table 3). (2015) (n=37) was a limitation of this study.

Rosenfield, Glassman and Capobianco
Preceptor support was identified in another study as an important need for the nurse resident (Rush, Adamack, Gordon & Janke, 2014). The consistent role of the NRP educator or skill expert can substitute as a preceptor in the cohort learning environment (Zinn, et al., 2012;Maxwell, 2011;Numminen, et al., 2015;Wiles, Simko & Schoessler, 2013). In several studies, the support of the preceptors was identified in three ways: giving them (nurse residents) little support, to great support and to the continued relationship as a mentor.
For many nurse residents the charge nurse is also seen as a preceptor (Wiles, et al., 2013). This study demonstrates the NRs beginning to see value in the mentorship relationship for future learning. One limitation of these studies was small sample size and inability to control variables across various hospital settings.
Separate studies of the long term outcomes of NRPs identified the curricula structure of NRPs as an important feature of success (Fiedler, Read, Lane, Hicks & Jegier, 2014;Rosenfeld, et al., 2015;Goode, et al., 2013). The necessary components of the curricula structure include: 12 months in length, cohort grouping, skill development and an evidenced based research project at the end of the NRP. These core components all support clinical reasoning development and clinical autonomy while strengthening the nurse resident's commitment to nursing. The underlying principle here is the fact that as the nurse resident feels successful in functioning by skill mastery and clinical reasoning, this helps them become competent and therefore a safe practitioner. Thus, their commitment to nursing increases, because the NR begins to see themselves as a competent nurse. This role identity is important. Many of these studies had limitations of a small sample size or single health system setting.
The original purpose of NRPs was to support the novice or advanced beginner nurse with their transition to practice in the first 12 months (Rosenfield, et al., 2015). Attempting to understand the quality of NRPs was the subject of one systematic review. This systematic review had 20 studies reporting data for programs for new registered nurses (nurse residents). In this systematic review, it was noted that most NRPs use a 12-month cohort model and use pre-and post-test design for program evaluation. Their design allows for data analysis within a cohort and the ability to compare cohorts across different periods of time. This data was shared with submission to Vizient for the purpose of sharing lessons learned; both about implementation and evaluation of NRPs.
In a similar study, Goode, et al. (2013), found that the nurse resident's ability to perform his or her work and competencies improved over a 12-month time frame. This was assessed through nurse resident's personal perception of his or her abilities to perform and prioritize the care needed for the patient. There was a statistically significant increase in the nurse residents' perception of their ability to provide clinical leadership during the 12-month NRP. Means (with standard errors in parentheses) for organizing and prioritizing care section of the pre-and posttest at the start, midpoint and completion of the NRP were 2.68 (0.03), 2.97 (0.03), and 3.10 (0.02) with p<.001. Letourneau and Fater (2015) conducted an integrative literature review by searching 10 empirical and 15 NRP development articles. Overall the authors determined NRPs support the nurse resident with their transition to practice, thus providing supporting evidence for nurse leaders and educators to implement and evaluate NRPs.
The remaining studies were focused on clinical reasoning. Wiles, et al., 2013 studied a small group of nurses (n=5) using a qualitative one-to one interview process and a working definition of clinical reasoning as a 'deliberative problem solving activity or process". Interviews were transcribed, coded and analyzed. The three themes emerged: confidence development in practice, asking for assistance, and decision making (clinical reasoning). The nurse residents who were interviewed used self-reflection during the decision making process. The limitation of this study was a small sample size (n=5). Twycross and Powls (2006) assessed the clinical reasoning of pediatric nurses in a hospital setting. The study design used a "think aloud" technique and the nurse residents talked out loud as they were thinking about an intervention for a patient. This technique is supported in an expert opinion paper by Pinnock and Welch (2014) that directly addresses the use of the 'think aloud' style for knowledge development. Clinical scenarios were applied and the narrative responses of the nurses were analyzed to describe how nurses make clinical decisions. It was noted that nurses used a hypothetico-deductive model to make clinical decisions. This means nurse residents used an analytical model to hypothesize an outcome for a nursing intervention.
The nurse resident would then deduce and predict the outcome with the final step being the observation of the outcome. The next step tests predictions and the nurse resident begins to use inductive reasoning. Nurse residents in this research study also used backwards reasoning in their decision making. The goal for the patient situation was discussed and the nurse residents' worked the patient situation backwards to create an outcome.
In a case study review by Maxwell (2011) , Clark & Springer, 2011, Wiles, et al., 2013. The NRP supports the nurse resident as they transition to practice.
Using a cohort model for participation creates an environment of learning and reflective sharing . The scheduled seminar sessions promote clinical reasoning as the nurse residents learn from trained preceptors or teachers (resident facilitators) and share their clinical experiences (Goode, et al., 2013;Wiles, et al., 2013). These sessions create opportunities to explore how clinical decisions were made and allow for self-reflection on future actions the next time a similar clinical situation occurs.
The literature review supports the need for NRPs. The nurse resident gains knowledge and skill in the first 12 months of entering their work environment. This foundational knowledge and skill acquisition is supported by the stable relationship with their preceptor, the charge nurse and the unit or hospital leadership Fiedler, et al., 2014;Goode, et al., 2013;Wiles, et al., 2013). Nurse residents reported feeling supported by resident facilitators or clinical experts in the NRP as they gained patient care knowledge and experience.

Research Design
A quasi-experimental, pre-and post-test assessment with a comparison group design was used for this project. The subjects for the pilot project were a convenience sample of new graduate nurses called nurse residents, hired to work in an academic medical center (AMC) in central Virginia. The inclusion criterion included participants who met all hiring standards set by the AMC. These newly hired nurses with an employment start date of July 18 were assigned to Cohort D, the intervention cohort. Cohort E, the control group, had an employment start date of August 1. The exclusion criteria included nurse residents not hired on July 18 or August 1.

Variables
The independent variable was the teaching and learning method used: resident facilitator model (Cohort D) or traditional classroom model (Cohort E). The dependent variable will be the difference between the overall pre-test and post-test score measures.

Setting
The pilot project was conducted in designated nurse education classrooms in the nurse education building that is geographically separate from the main AMC building. There were no make-up dates for the pre-tests or post-tests.

Data Analysis Plan
Insight Assessment presented initial analysis of average overall scores and individual scale scores for the HSRT-N in excel spreadsheet, group histograms and descriptive statistics for both cohorts tested. The descriptive statistics include: size of the group, mean, median, standard deviation, standard error of the mean, lowest score, highest score, first quartile score and third quartile score. The analytics provided performance scores in these sub-categories of clinical reasoning: analysis, interpretation, evaluation, explanation, inference, deduction, and induction and overall reasoning skills. Insight Assessment's definitions of the performance sub-categories are:  Analysis-reasoning skills enable people to identify assumptions, reasons and claims and to examine how they interact in the formation of arguments.
 Interpretation-skills are used to determine the precise meaning and significance of a message, icon, chart, spoken word or gesture.
 Evaluation-evaluative reasoning skills enable people to assess the credibility of sources of information and the claims they make such as in the use of evidence based practice.
 Explanation-explanatory reasoning skills when used prior to making a final decision enable people to discover, test and to articulate the reasons for actions, beliefs or decisions.
 Inference-skills to assist people in drawing conclusions from reasons and evidence.
Conclusions, hypotheses or decisions may be based on faulty analysis but had excellent inference skills used in the process for decision making.
 Deduction-this reasoning moves with precision from an assumed truth of beliefs to A paired t-test was used to detect significant differences in normally distributed continuous data between pre-and post-test assessment overall scores and the eight sub-categories.
Comparative statistics were done to identify if significant differences between demographic groups and category mean scores were found. Statistical significance (α) was determined at 0.05 or less.

Protection of Human Subjects
Following project proposal approval, an ethical research review was conducted by Institutional Review Board for Social and Behavioral Sciences (IRB-SBS). The project and instrument was approved, IRB-SBS: #2016-0299-00. The approved participant consent form for the NRs is included as Appendix D.

Strengths and Limitations of the Project
The literature reveals that NRPs may improve first year retention; positively impact new graduate confidence and improve nurse resident competence. One strength of the project is using a reliable and validated instrument for assessing clinical reasoning (HSRT-N). The project also contributes to the body of nursing knowledge on new nurse transition to practice, and NRPs curriculum planning.
Project limitations included the lack of randomization of subjects and small sample size of the matched pairs (n=25, n=20). Other limitations of the project were variability in RF experience and comfort using the Socratic teaching method with small group facilitation and the inability to control how the RF utilized the 'what if', 'talk aloud' and case-based scenarios. The study attempted to control for this by requiring all RFs to go through the RF training that included Socratic questioning techniques and topics on critical thinking.

RESULTS
The HSRT-N online assessment data was collected by the Insight Assessment Company and retrieved for this project by web access. Data was analyzed using matched pairs for the intervention and control cohorts. The sample size of the cohorts was appropriate to analyze (n=25 and n=20  Table 6 for statistical analysis of sublevels of clinical reasoning.
The NRs had the opportunity to attend other cohort sessions due to work schedules or illness. There was intervention cohort and control cohort attendance crossover of the 4 class sessions. A variance noted was attendance at the NRP sessions. The control group had a matched pairs n=20 compared to the matched pairs for the intervention cohort n=25. See Table 7. Data was compared on the demographics on who attended the 4th session and who missed the 4th session and it was not significant. See Table 8.

DISCUSSION
Clinical reasoning is an expected outcome as NRs build their knowledge and skill to safely care for patients. The NRs in this project are all in Benner's Stage 2: Advanced Beginner phase of knowledge and skill acquisition; with less than 12 months on the job. The curricula of NRPs aid in clinical knowledge acquisition Goode, et al., 2013). Development of critical thinking improves the clinical reasoning ability of the NR and the ability to apply their knowledge and skill to an individual patient .
Socratic questioning provided an opportunity for NRs in the intervention cohort to break into small discussion groups for sharing clinical experiences and learning. These small groups were divided by specialty practice settings to provide an opportunity for the NRs to hear and learn from similar patient and clinical experiences. These small break out groups allowed opportunities for NR sharing in an intimate setting different from the large classroom style environment of the control cohort. The RFs for the intervention sessions were trained in the use of Socratic questioning. The project was not able to control for the individual RF nuances in leading Socratic questioning sessions. It is unknown if this factor had an influence on the intervention cohort data.
Explanation can be defined as the NR being able to discuss in a clear, logical and pertinent way the results of their clinical reasoning about a specific patient or in the case of this project, the online case study. The NR has not yet developed big picture thinking. The Insight Assessment Corporation describes explanation as the ability to use explanatory reasoning skills when making a final decision. Being able to explain lets NRs discover, test and articulate the reasons for clinical decision making. This project is unable to explain why the intervention group had a lower score in the explanation subtype of learning and the control cohort had an improved score in the explanation subtype. Figures 2 through 9 show the data in histogram format for the intervention cohort and the control cohort, displaying nurse resident scores without identifiers.
NRs noted preference for small group RF led Socratic questioning sessions through unsolicited comments from control cohort NRs who attended an intervention makeup NRP session. NRs who had experienced an intervention session expressed that every NRP class "should be done that way" and "I like spending time with other nurses in my area". Many requested that the rest of their NRP be done in the breakout session model.

Implications for Nursing
Research supports the use of NRPs for the NRs . NRs benefit from good relationships with preceptors or instructors (Goode, et al., 2013;Wiles, et al., 2013).
This project did not support the use of Socratic questioning in a NRP for improving the overall HSRT-N clinical reasoning score. There was statistical significance in the explanation sublevel of knowledge development, demonstrating that this area of critical thinking may need attention as NRP curriculums are refined in the future. There is also an opportunity to educate the preceptors in the area of 'explanation' for the NRs. This project did not show that clinical reasoning was improved using the HSRT-N as our measure. The results of this study will be used by the project's AMC setting to support design and resource allocation decision-making for their existing NRP including development of resident facilitator training program; a preceptor training in the use of Socratic questioning and possible creation of new computer-based learning modules.

Products of the Project
The results of the piloted RF model can be shared with other nurse resident programs and  60% of all respondents reported the need for peer support in the first 1-3 months of employment  Use of reflection on practice allows the nurse resident to think about the situation and work through how they would handle it the next time it occurs.  Pediatrics-Acute 0 (0%) 3 (15%) Procedural 0 (0%) 1 (5%) OR 4 (16%) 0 (0%) PACU 2 (8%) 1 (5%) Neonatal 0 (0%) 2 (10%) L and D/Women's 3 (12%) 0 (0%) Ambulatory 2 (8%) 0 (0%) ED is Emergency Department, OR is Operating Room, PACU is Post Anesthesia Care Unit, L and D is Labor and Delivery Table 5.  CI 95%, p≤0.05: Independent t test computed. The overall score was not found to be statistically significant. The explanation score for the control group had a greater improvement than the intervention group and was found to be statistically significant.  Class attendance varied with some NRs missing due to work schedules or illness. NRs had the opportunity to attend other make-up classes and this also altered the attendance numbers.   .

Cohort D-Intervention group-pre-test: OVERALL score
This figure shows the Intervention group's OVERALL score on the pre-test. The colors represent score levels set by Insight Assessment. Yellow and green are labeled moderate and strong categories. You can see that most participants in the Intervention cohort scored in the moderate and strong levels. There were participants in the superior score levels. X axis displays score ranges in numeric and color legend on right side of histogram. Y axis displays number of NR respondents.

Figure 2. Cohort D-Intervention group-pre-test: OVERALL score.
Results from: Insight Assessment; a division of The California Academic Press LLC, San Jose, CA., USA. No permission needed for use of the histograms.

Cohort D-Intervention group-post-test: OVERALL score
This figure shows the Intervention group's OVERALL score on the post-test. The colors represent score levels set by Insight Assessment. Yellow and green are labeled moderate and strong categories. You can see that most participants in the Intervention cohort scored in the moderate and strong levels. In the post-test there were more participants that scored in the weak category. There were also participants in the superior score levels. X axis displays score ranges in numeric and color legend on right side of histogram. Y axis displays number of NR respondents.

Cohort D-Intervention group-pre-test: EXPLANATION score
This figure shows the Intervention group's EXPLANATION score on the pre-test. The colors represent score levels set by Insight Assessment. Yellow and green are labeled moderate and strong categories. You can see that most participants in the Intervention cohort scored in the moderate and strong levels. There was a participant that scored in the weak category. There were also participants in the superior score levels. X axis displays score ranges in numeric and color legend on right side of histogram. Y axis displays number of NR respondents.

Cohort D-Intervention group-post-test: EXPLANATION score
This figure shows the Intervention group's EXPLANATION score on the post-test. The colors represent score levels set by Insight Assessment. Yellow and green are labeled moderate and strong categories. You can see that most participants in the Intervention cohort scored in the moderate and strong levels. There was a participant that scored in the weak category. There were also participants in the superior score levels. X axis displays score ranges in numeric and color legend on right side of histogram. Y axis displays number of NR respondents.

Cohort E-Control group-pre-test: OVERALL score
This figure shows the Control group OVERALL score on the pre-test. The colors represent score levels set by Insight Assessment. Yellow and green are labeled moderate and strong categories. You can see that most participants in the Intervention cohort scored in the moderate and strong levels. There were two participants that scored in the weak category. There were also participants in the superior score levels. X axis displays score ranges in numeric and color legend on right side of histogram. Y axis displays number of NR respondents.

Cohort E-Control group-post-test: OVERALL score
This figure shows the Control group OVERALL score on the post-test. The colors represent score levels set by Insight Assessment. Yellow and green are labeled moderate and strong categories. You can see that most participants in the Intervention cohort scored in the moderate and strong levels. There was a participant that scored in the weak category. There were also participants in the superior score levels. One participant was in the not manifested category. This participant's test could not be scored as it was not completed in the allotted time. X axis displays score ranges in numeric and color legend on right side of histogram. Y axis displays number of NR respondents.

Cohort E-Control group-pre-test: EXPLANATION score
This figure shows the Control group EXPLANATION score on the pre-test. The colors represent score levels set by Insight Assessment. Yellow and green are labeled moderate and strong categories. You can see that most participants in the Intervention cohort scored in the moderate and strong levels. There were also participants in the superior score levels. One participant was in the not manifested category. This participant's test could not be scored as it was not completed in the allotted time frame. X axis displays score ranges in numeric and color legend on right side of histogram. Y axis displays number of NR respondents.

Cohort E-Control group-post-test: EXPLANATION score
This figure shows the Control group EXPLANATION score on the pre-test. The colors represent score levels set by Insight Assessment. Yellow and green are labeled moderate and strong categories. You can see that most participants in the Intervention cohort scored in the moderate and strong levels. There were also participants in the superior score levels. X axis displays score ranges in numeric and color legend on right side of histogram. Y axis displays number of NR respondents.   Conflicts of Interest: Sharon Bragg manages a medical intensive care unit at the academic medical center that participates in the institution's nurse residency program. Susan B. Galloway directs the institution's nurse residency program. For the remaining authors, no conflicts of interest were declared.

Abstract
Project evaluated clinical reasoning skills of nurse residents in a nurse residency program using a resident facilitator model embedded with Socratic questioning and peer reflection group techniques. Intervention and control cohorts were assessed using a web-based instrument with pre-test and post-test assessments. Comparative analysis demonstrated no statistically significant difference between the intervention cohort (M= -.800, SD=4.79) and the control cohort (M=0.20, SD=5.33) in the improvement of clinical reasoning; t (43) = -.661, p=.512 > 0.05).
Nurse residency programs (NRP's) are important to the growth and clinical development of new nurses as they transition to practice, however most nurse residents lack the level of clinical reasoning needed to safely care for patients (Letourneau & Fater, 2015). The Institute of Medicine describes NRP's as "planned, comprehensive periods of time during which nurse residents can acquire the knowledge and skills to deliver safe, quality care that meets defined (organizations or professional society) standards of practice" (2011, p 120-121). NRPs require a curriculum that connects to a nurse's daily clinical practice and covers content applicable to nursing practice (Zinn, Guglielmi, Davis & Moses, 2012).

Introduction
The American Association of Colleges of Nursing (AACN) and the National League for Nursing Accrediting Commission (NLNAC), both accrediting agencies for nurse education programs, set the standards for nursing education programs. Both organizations treat the concept of critical thinking as a core element of nursing curricula and require measurement of this concept as an outcome in evaluating nursing education programs. Vizient formerly known as the University Hospital Consortium, is an alliance of the nation's leading nonprofit academic medical centers and their affiliated hospitals and is focused on delivering world-class patient care. In March 2000, the Consortium and accrediting bodies collaborated in developing an evidence-based curriculum for the graduate nurse, called the Nurse Residency Program™ (NRP), to improve new graduate transition to practice and patient care (Vizient, 2016a). The NRP curriculum requires specific competency development in critical thinking and leadership abilities (Vizient, 2016b). Participating hospitals use a 12-month customizable curriculum framework that emphasizes critical thinking and clinical reasoning skill development through new graduate peer group interactions and self-reflection. The NRPs framework curriculum aids in clinical knowledge acquisition Goode, McElroy, Bednash & Murray, 2013). As critical thinking develops, the clinical reasoning ability of the nurse resident develops. Clinical reasoning is defined as a situated, practice-based form of reasoning that requires the nurse resident to have a beginner knowledge level about general nursing skills and interventions and their application to a specific patient situation . Clinical reasoning can also be defined as the ability to sort through many details and develop a plan, change a plan or intervene appropriately within that plan (Pinnock & Welch, 2014). With a final sample of 13 articles, six of the articles focused on the nurse residents' transition to practice and clinical reasoning development. Three of the articles were systematic reviews of nurse residency programs. Four articles focused on the implementation of NRPs.

Pertinent Findings of Literature Review
The purpose of the literature review was to review NRPs and clinical reasoning. There were studies and articles that evaluated new resident nurse related to their knowledge development. Many studies addressed the Benner novice to expert framework (1984) and how it describes the knowledge and skill development of nurses. In combining skill acquisition theory and knowledge theory with the design of the NRPs, similar themes emerged in the literature review. Two basic components of the NRPs include: a set curricula design and a supportive preceptor. The evidence establishes that part of the acquisition of new knowledge should be the use of a resident facilitator during case based scenarios, and subsequent self-reflection by the nurse resident , Clark & Springer, 2011, Wiles, Simko, Schoessler, 2013.
NRPs demonstrated their assistance to the nurse resident as they transitioned to practice. Fiedler, Read, Lane, Hicks & Jegier, 2014;Goode, et al., 2013;Wiles, et al., 2013). Using a cohort model for participation creates an environment of learning and reflective sharing . The scheduled seminar sessions promote clinical reasoning as the nurse residents learn from trained preceptors or teachers (resident facilitators), and share their clinical experiences (Goode, et al., 2013;Wiles, et al., 2013). These sessions provide opportunities to explore how clinical decisions are made and allow for self-reflection on future actions the next time a similar clinical situation occurs.
The literature review supports the need for NRPs. The new nurse resident gains knowledge and skill in the first 12 months of entering their work environment. The nurse resident's foundational knowledge and skill acquisition is supported by the stable relationship with their preceptor, the charge nurse and the unit or hospital leadership Fiedler, et al., 2014;Goode, et al., 2013;Wiles, et al., 2013). Nurse residents reported feeling supported as they gained knowledge to care for patients and gained experience in the NRP settings led by resident facilitators or clinical experts.

Methodology
The use of a resident facilitator model can support the successful transition for the new nurse resident. The use of case studies for nursing education is an established method utilized for skill and knowledge development. Clinical reasoning is a deliberate process where conclusions are identified using actual experiences or suggested interventions in case based scenarios. The aim of the pilot project was to evaluate the use of a resident facilitator model after nurse residents had sessions using Socratic questioning and case based 'what if' scenarios using an assessment instrument for clinical reasoning improvement at the end of the NRP. The nurse residents were prompted with questions during these case based scenarios. The Socratic seminar was led by a resident facilitator who had been trained to use Socratic questioning. As the nurse residents participated in the discussion and also listened to the comments of others, they can begin to think critically for themselves. Socratic questioning, or thinking about how to think, and the 'talk aloud' method (Pinnock & Welch, 2013) can enhance critical thinking and clinical reasoning.
This pilot project was a quasi-experimental, pre-test and post-test design with a comparison group analysis. The subjects for the pilot project were a convenience sample of new graduate nurses (nurse residents) hired to work in an academic medical center (AMC) in central Virginia. The inclusion criterion included participants who met all hiring standards set by the AMC and nurse residents assigned to specific cohorts by the date of hire.

Research Design
The AMC supported the purchase of electronic seats for the nurse residents to access an online assessment instrument. The HSRT-N is a content-validated, online, clinical reasoning assessment instrument (Insight Assessment, June 2016; Facione, 1990).
Prior to this project, the NRP used a classroom style for all twelve of the NRP sessions.
This project planned four NRP classroom sessions, utilizing Socratic questioning in conjunction with small breakout groups based on specialty areas worked. The pre-test assessment tool and the post-test assessment tool were administered to the intervention cohort and the control cohort in specific scheduled sessions. The data were collected online by the Insight Assessment and retrieved by web access by the project investigator.
The HSRT-N measurement instrument provided a discipline neutral measure of reasoning skills and is widely used to assess clinical reasoning in the health care field. The HSRT-N assessed critical thinking and reasoning in case based scenarios. The measurement did not test knowledge. The online assessment consisted of 38 scenario based multiple choice questions.
The pre-test HSRT-N was administered using internet access and laptop computers furnished by the NRP to the intervention group, Cohort D, and control group, Cohort E, during their respected class sessions. After Institutional Review Board (IRB) approval, the online assessments were administered October 2016 and November 2016, respectfully (IRB #2016-0299-00). The post-test was administered to the intervention group, Cohort D (n=25), in April 2017 and the control group, Cohort E (n=20), in May 2017. This project was not able to alter the established dates of the NRP cohorts related to scheduling pre-tests and post-tests.
Data were analyzed using matched pairs for the intervention and control cohorts using a 0.05 level of significance with data points. The sample size of the cohorts was appropriate to analyze.
The matched pairs for the intervention cohort was predominantly female n= 22 at 88%.  Table 2 and Table 3 for details.) A variance identified was NRP session attendance. The NRs had the opportunity to attend other cohort sessions if needed due to work schedules or illness, so there was intervention cohort and control cohort attendance crossover at some of the 4 sessions. Computer logins for each cohort helped assure that pre-tests and post-tests were done correctly. The demographic characteristics data were compared on who attended the 4th session and who missed the 4th session. Cross tabulation tests were also performed on the demographics of gender, ethnicity, RN degree level and areas worked. This was not significant.

DISCUSSION
Clinical reasoning is an expected outcome as NRs build their skill and knowledge to safely care for patients. The NRs in this project are all in Benner's Stage 2: Advanced Beginner phase of knowledge and skill acquisition; with less than 12 months on the job. The curricula of NRPs aid in clinical knowledge acquisition Goode, et al., 2013). Critical thinking development improves the clinical reasoning ability of the NR and the ability to apply the knowledge and skill to an individual patient . The resident facilitator model provided an opportunity for NRs in the intervention cohort to break into small discussion groups for the purpose of sharing clinical experiences and learning. These small groups were divided by areas worked so the NRs could hear and learn from their similar patient experiences. These small break-out groups allowed opportunities for sharing in an intimate setting for the NR. The RFs for the intervention sessions were trained in the use of Socratic questioning with a 4-hour training session. The project was not able to control for the individual nuances of leading the sessions by the RF who was instructed in the use of Socratic questioning. It is unknown if this factor had an influence on the intervention cohort or control cohort data.
The project does not demonstrate why the explanation subtype of learning category score for the intervention cohort was lower. You may conjecture that the NR not being able to discuss in a clear, logical and pertinent way what their clinical reasoning was in situations. Most NRs have not yet developed visionary thinking. The project does not demonstrate why the control cohort had an improved score in the explanation subtype of learning category. Being able to explain allows NRs to discover, test and articulate the reasons for their clinical decision making.
Unsolicited feedback from control group participants who attended an intervention session indicated that the small group RF Socratic questioning sessions were preferred. NRs who had experienced an intervention session expressed that every NRP class "should be done that way" and "I like spending time with other nurses in my area". Many requested that the rest of their NRP be done in the resident facilitator breakout session model using Socratic questioning.

Implications for Nursing
Research supports the use of NRPs for the NRs . NRs benefit from mentoring and teaching relationships with preceptors or instructors (Goode, et al., 2013;Wiles, et al., 2013). This project provided evidence that the nurse facilitator model with embedded Socratic questioning in a NRP did not improve the overall score when using the HSRT-N instrument. There was statistical significance in the explanation subtype of knowledge development, demonstrating that this area of critical thinking may need attention as NRP curriculums are developed in the future. There is also an opportunity to educate the preceptors/nurse facilitators in the area of 'explanation' for the NR. The use of Socratic questioning and the focus on building explanation skills can support NRs as they attend NRP classes and have clinical experiences in their work areas. A future longitudinal study would strengthen understanding of how the use of a nurse facilitated with embedded Socratic questioning may improve clinical reasoning. Future studies should assess if employment retention rates or specific patient outcomes improve for NRs transitioned to practice using a nurse facilitation model with embedded Socratic questioning and small peer group reflection techniques.