Title: Can We Use The Key Feature Tests For The Assessment Of Clinical Reasoning Of Nursing Students?

Dear editorClinical reasoning is considered as a process of applying knowledge and experience in a clinical setting to solve a problem. There are many types of clinical reasoning, each with a special application. Reasoning involves the process of cognition, thinking, and metacognition. In nursing, clinical reasoning is considered as one of the components expected by nurses with experience and efficiency (1). Clinical reasoning tests are composed of: Key feature test, clinical reasoning problem, patient problem management, comprehensive integrated puzzle and script concordance (2). The most common type is the patient problem management test (3.4). This test consists of a clinical scenario and some choices about history taking, clinical exam, assessment and diagnosis. Since this test has a low reliability so it needs a plenty of time to achieve optimal reliability. The common form of this test needs 90 minutes to be answered. In many cases, the scoring of this test is attributing to the ability of data collection, rather than decisionmaking, and has a close relationship with the knowledge assessment test (4). At a conference at Cambridge University in 1989, Page stated that to solve clinical problems, all the symptoms and elements do not have the same value and few elements are important in the diagnosis and resolution of a clinical problem (5). The medical consulting center conducted many studies for the substitution of the KF test with the PMP test. The PMP test uses elaborated and expanded scenarios which consisted of detailed subjects. It is possible to use a real situation or to omit and change some patient information. Scenarios should be enriched and consist of many important pieces of information to depict a patient #39;s real life (6). It rsquo;s time consuming. KF test is suitable for assessing the ability of students in data collection and emphasizes the elements in which students tend to make mistakes (7). This test has a description (a description of a clinical situation) and some choices. The signs and symptoms are presented in such a way as to avoid giving guidance and clue to the student in the following sections. After the description of the clinical problem, there are usually answers (options) (811). Choices are 1015 and up to the correct choices can reach 20 in some cases, depending on the number of correct answers, the number of options is changed (12,13). KF tests are so enriched that the students should integrate their information and make a decision. So it can assess the decisionmaking ability. It has a high reliability because of many issues. Content validity of this test increased because of paying attention to the key elements. Canada Medical Consulting Center from 1992, Maastricht University since 1993 and Australia University since 1996 have been using the KF test for evaluating the clinical decision making of medical student at general, specialized and fellowship levels. The University of Toronto also uses this test to assess the first and second year students (14). The results of the study by Zimany et al (2017) on evaluating the clinical judgment of 59 midwifery students using Key Feature test and the conventional multiplechoice questions showed that the average score of the test with key features was 10.9 out of 20, and the mean score the multiplechoice test was 8.88. The authors, based on the difficulty index, the discrimination ability of the test and the Cronbach #39;s alpha coefficient, suggested that clinical reasoning cannot be measured with multiplechoice questions. Therefore, the use of innovative evaluation tools in clinical domains is recommended by using the key features (KF) test. (15). The researcher (as a clinical mentor) has a new experience in applying KF test to assess clinical decisionmaking skills in junior nursing students for posttest in urology ward. A sample question is mentioned below. Since it was a priority to make nursing students interested in an innovative type of clinical evaluation test, the result of the correct answer to this test has not had any effect on the endpoint score. Although, in general, each of the three correct answers had a score, choosing more options would result in a lack of consideration for the rating for the individual. No negative rating was used. A 52yearold man with fever and shivering and productive cough that had started from 24 hours ago came to the hospital. At the time of being admitted, his blood pressure was 110 / 70mmhg, temperature was 38.8 and pulse rate was 110 PPM (tachycardia). What is your nursing priority? (3 choices)1. Wearing mask for preventing infection transmission2. Wet sponges for temperature decreasing3. Acetaminophen for temperature decreasing4. Connecting the oximeter pulse to the patient #39;s finger5. Cardiac monitoring6. Recommendation for plenty of fluid intakes7. Applying supplement oxygen with face mask8. IV insertion9. Reducing patient coverage10. Complete bedrest11. Highprotein dietThis test is used for the student of medicine in many levels for evaluating decisionmaking skills but there is no evidence for applying this test to nursing students. It seems clinicians are not able to assess the clinical judgment of a nursing student in subjects such as nursing diagnosis, prioritizing nursing care and modalities. Nursing and Midwifery Development Offices are expected to promote the culture of using tests that measure higher levels of thinking, and apart from conducting research studies, provide solid evidence for the effectiveness of the test with key features in nursing.