Clinical judgment: the last frontier for evaluation

Addressing the 2021 Essentials with new approaches for developing leadership, resilience, and self-care/well-being in undergraduate baccalaureate nursing students

INTRODUCTION

New graduate nurses are not always prepared for the challenges of the chaotic clinical environment or to exercise leadership skills in a clinical capacity. Resilience and self-care are essential facets of successful leadership, as well as necessary components to prevent burnout in nurses.

PURPOSE

The purpose of this article is to demonstrate how this School of Nursing implemented approaches to prepare the next generation of nurses with strong skills in the areas of leadership, resilience, and self-care/well-being while addressing the Essentials.

METHODS

Faculty explored new ideas, as well as showcased teaching strategies they had already successfully implemented, that aligned with the Essentials with the undergraduate baccalaureate pilot student cohort.

RESULTS

Two "Essential" Competencies, Domain 9 Professionalism and Domain 10 Personal, Professional and Leadership Development, as well as related sub-competencies, were addressed by the thirteen teaching strategies. Anecdotal student reflection comments supported high levels of satisfaction with these strategies.

CONCLUSIONS

Preparing student nurses to meet the Essentials is critical to helping nurses thrive in contemporary practice settings. Equipping a generation of nurses with self-care practices to protect their own well-being, while at the same time meeting the Essentials expectations, is crucial to cultivating a sustainable nursing workforce.

Comparative study of clinical reasoning competence and self-directed learning competence in nurses across varied years of experience

OBJECTIVES

To compare and analyse the differences in the clinical reasoning competence of nurses with different working years and their relationship with self-directed learning competence.

METHODS

A cross-sectional survey design (online investigation) was used. A total of 376 nurses were recruited from four independent hospitals in China. Online questionnaires collected data on nurses' demographic characteristics and assessed their clinical reasoning and self-directed learning competence. Pearson correlation analysis, t-test, analysis of variance (ANOVA) and multivariate regression analysis were used.

RESULTS

Clinical reasoning competence scores of nurses with working years >10 years were higher than those of other nurses. Self-directed learning competence scores of nurses with working years of <1 year and (from ≥1 year to <3 years) were lower than those of nurses with working years of 6-10 years and >10 years. Self-directed learning competence scores of nurses with working years of 3-5 years were lower than those of nurses with working years of >10 years. There was a positive correlation between clinical reasoning competence, self-directed learning competence and each dimension among nurses of different working years. There are differences in the influence of different dimensions of self-directed learning competence on clinical reasoning competence among different working years.

CONCLUSION

There were differences in clinical reasoning and self-directed learning competence among nurses with different working years. Self-directed learning competence is a positive predictor of nurses' clinical reasoning competence, which applied to nurses with all working years; however, the specific effect of self-directed learning competence on clinical reasoning competence differed among nurses with different working years.

IMPLICATION FOR NURSING MANAGERS

Nursing managers should pay attention to the development characteristics of clinical reasoning competence and self-directed learning competence of nurses with different working years and determine effective intervention strategies according to specific influencing factors.

The Lasater Clinical Judgment Rubric: 17 Years Later

BACKGROUND

Nearly 17 years ago, the Lasater Clinical Judgment Rubric (LCJR) was published to provide a common language and trajectory of students' development to think like a nurse.

METHOD

This article traces the uses of the LCJR from creation to the present and cites lessons learned from its use.

RESULTS

During the intervening years, the LCJR has been used effectively as a debriefing guide in simulation and as a research instrument, as well as for formative assessment. The LCJR has been translated or is in process in 19 languages besides English.

CONCLUSION

This article provides evidence of the efficacy of the LCJR and discusses important lessons learned. [J Nurs Educ. 2024;63(3):149-155.].

The implementation of Tanner's Clinical Judgment Model and the Indonesian version of the Lasater Clinical Judgment Rubric in the clinical setting

A critical component for nurses to provide safe and quality care with strong patient outcomes is clinical judgment. This study aimed to identify the difference in the clinical judgment score in newly graduated nurses by implementing Tanner's Clinical Judgment Model. This study followed an experimental design with a pretest-posttest and involved thirty-two newly graduated nurses from three private hospitals in Indonesia. The intervention group had a scheduled post-conference with their preceptors using Tanner's Clinical Judgment Model's guidelines with high-level, open-ended questions for two consecutive weeks. Independent samples t-test was used to compare pre-and post-test scores utilizing the valid and reliable Indonesia version of the Lasater Clinical Judgment Rubric. There was no significant difference between the pre-test results of the intervention and control groups, with a significance value of 0.647. The results indicated a significant difference in the mean clinical judgment scores between the intervention and control groups after two weeks of intervention, where the intervention group's scores were higher than the control group's with a significance value of <0.001 with a mean difference of 6.75 and CI of 95 % (4.18-9.31). Tanner's Clinical Judgment Model showed a significant impact in increasing clinical judgment scores. The Indonesia version of the Lasater Clinical Judgment Rubric is a valuable tool for assessing and evaluating the development of clinical judgment and provides detailed targeted areas needing improvement. Preceptors and nursing leaders in the clinical setting should continue to use this model and tools to assist newly graduated nurses in developing clinical judgment skills during their transition period.

Mapping Critical Thinking, Clinical Reasoning, and Clinical Judgment Across the Curriculum

BACKGROUND

Critical thinking, clinical reasoning, and clinical judgment are skills nurses use when caring for clients. However, teaching and evaluation of clinical judgment are challenging for faculty.

PROBLEM

Before revising a curriculum, it is necessary to map current practices and determine a framework for revisions.

APPROACH

Faculty mapped critical thinking, clinical reasoning, and clinical judgment activities across the 5-semester traditional baccalaureate program. Use of an external consultant helped faculty to determine additional activities that could be used to assess clinical judgment in classroom and clinical settings. Faculty worked together to develop teaching strategies and Next Generation National Council Licensure Examination (NCLEX) item types for assessing clinical judgment.

CONCLUSION

Using the National Council of State Boards of Nursing Clinical Judgment Model as an educational framework can guide faculty in curriculum mapping, revisions, and development of clinical judgment activities and assessment.

Translation, cross-cultural adaptation and evaluation of the Iranian Persian version of student survey on writing nursing care plan

AIM

The objective of this study was to validate the Iranian translation and cross-cultural adaptation of the Student Survey on Writing Nursing Care Plan (SSW-NCP).

BACKGROUND

To provide supporting evidence about the nursing students' skill in planning and documenting nursing care plans based on nursing process, Salvador et al. developed the SSW-NCP to measure the extent to which nursing students are qualified in writing nursing care plans. However, an Iranian version of the SSW-NCP is presently not available.

METHOD

The cross-cultural adaptation and linguistic translation of the SSW-NCP adhered to World Health Organization (WHO) guidelines. The reliability and validity process followed the COSMIN checklist.

RESULTS

The survey was well translated to Persian language and culturally adapted through confirming the relevancy, appropriateness and logical representation of all aspects on nursing process by bilingual experts and pre-tested on Persian-speaking nursing students. The Cronbach's Alpha coefficient (α) and test-retest stability assessing affirmed the reliability, and convergent validity of the adapted survey was confirmed through comparison to Influencing Factors of Nursing Students' Clinical Judgment (IFNSCJ). The adaptation process of the SSW-NCP resulted in a conceptually equivalent translated version, which is comparable to the original version and is acceptably valid and reliable.

IMPLICATIONS FOR NURSING MANAGEMENT

Knowing the proficiency of nursing students as future nurses in writing nursing care plans can provide accurate professional information for better educational and practical level programming and management that can enhance nursing practice.

PATIENT OR PUBLIC CONTRIBUTION

The target group of survey was nursing students who contributed and participated in the current study.

Reflective Transition Practice Model: The New Graduate Registered Nurse

Reflection is a strategy that may enhance transition into practice for the new graduate registered nurse (NGRN). If introduced in the early stages of practice, reflection can be used as a tool to continuously evaluate and improve practice. A theory synthesis of Meleis' transition theory and Schon's reflective practice model was developed to support reflection as a tool for new nurses transitioning into the role of professional nurses. Reflection has the potential to improve the NGRNs' perception of their role, decrease feelings of disconnectedness, and improve patterns of response.

Lasater clinical judgment rubric reliability for scoring clinical judgment after observing asynchronous simulation and feasibility/usability with learners

BACKGROUND

There is strong evidence supporting using the Lasater Clinical Judgment Rubric (LCJR) for scoring learners' clinical judgment during in-person simulation performance and clinical experience reflections. However, a gap exists for using LCJR to evaluate clinical judgment after observing asynchronous simulation.

OBJECTIVE

We aimed to determine the reliability, feasibility, and usability of LCJR for scoring learners' written reflections after observing expert-modeled asynchronous simulation videos.

DESIGN/SETTING/PARTICIPANTS

We used a one-group, descriptive design and sampled pre-licensure, junior-level bachelor's learners from the Southwestern United States.

METHODS

Participants observed eight expert-modeled asynchronous simulation videos over one semester and provided written responses to clinical judgment prompts. We scored clinical judgment using LCJR. We studied reliability by measuring internal consistency of 11 clinical judgment prompts and interrater reliability with two raters. This study also investigated feasibility and usability of the asynchronous simulation learning activity using descriptive statistics. Feasibility included time learners spent completing written responses and time raters spent evaluating written responses. Learners reported usability perceptions using an instructor-developed survey.

RESULTS

Sixty-three learners completed 504 written responses to clinical judgment prompts. Cohen's kappa ranged from 0.34 to 0.86 with a cumulative κ = 0.58. Gwet's AC ranged from 0.48 to 0.90, with a cumulative AC = 0.74. Cronbach's alpha was from 0.51 to 0.72. Learners spent on average 28.32 ± 12.99 min per expert-modeling video observation. Raters spent on average 4.85 ± 1.34 min evaluating written responses for each participant. Learners reported the asynchronous learning activity was usable.

CONCLUSIONS

Nurse educators can reliably use LCJR for scoring learners' clinical judgment after observing asynchronous expert-modeled simulation. Logistically, learners complete the reflective learning activity and faculty use LCJR to measure clinical judgment in feasible time. Further, participants perceived the asynchronous learning activity usable. Nurse educators should utilize this learning activity for evaluating and tracking observer clinical judgment development.

Assessing trainee's performance using reported observations: Perceptions of nurse meta-assessors

BACKGROUND

Educational and health care organizations who prepare meta-assessors to fulfill their role in the assessment of trainees' performance based on reported observations have little literature to rely on. While the assessment of trainees' performance based on reported observations has been operationalized, we have yet to understand the elements that can affect its quality fully. Closing this gap in the literature will provide valuable insight that could inform the implementation and quality monitoring of the assessment of trainees' performance based on reported observations.

OBJECTIVES

The purpose of this study was to explore the elements to consider in the assessment of trainees' performance based on reported observations from the perspectives of meta-assessors.

METHODS

Design, Settings, Participants, data collection and analysis. The authors adopted Sandelowski's qualitative descriptive approach to interview nurse meta-assessors from two nursing programs. A semi-structured interview guide was used to document the elements to consider in the assessment of nursing trainees' performance based on reported observations, and a survey was used to collect sociodemographic data. The authors conducted a thematic analysis of the interview transcripts.

RESULTS

Thirteen meta-assessors participated in the study. Three core themes were identified: (1) meta-assessors' appropriation of their perceived assessment roles and activities, (2) team climate of information sharing, and (3) challenges associated with the assessment of trainees' performance based on reported observations. Each theme is comprised of several sub themes.

CONCLUSIONS

To optimize the quality of the assessment of the trainee's performance based on reported observations and ratings, HPE programs might consider how to clarify better the meta-assessor's roles and activities, as well as how interventions could be created to promote a climate of information sharing and to address the challenges identified. This work will guide educational and health care organizations for better preparation and support for meta-assessors and preceptors.

Nursing students' clinical judgment skills in simulation and clinical placement: a comparison of student self-assessment and evaluator assessment

BACKGROUND

Clinical judgment is an important and desirable learning outcome in nursing education. Students must be able to self-assess their clinical judgment in both the simulation and clinical settings to identify knowledge gaps and further improve and develop their skills. Further investigation is needed to determine the optimal conditions for and reliability of this self-assessment.

AIMS

This study aimed to compare the same group of students' self-assessment of clinical judgment with an evaluator's assessment in both simulation and clinical settings. The study further aimed to investigate whether the Dunning-Kruger effect is present in nursing students' self-assessment of clinical judgment.

METHODS

The study applied a quantitative comparative design. It was conducted in two learning settings: an academic simulation-based education course, and a clinical placement course in an acute care hospital. The sample consisted of 23 nursing students. The Lasater Clinical Judgment Rubric was used to collect data. The scores were compared using a t-test, intraclass correlation coefficient, Pearson's correlation coefficient, and Bland-Altman plots. The Dunning-Kruger effect was investigated using linear regression analysis and a scatter plot.

RESULTS

The results showed an inconsistency between student self-assessment and evaluator assessment of clinical judgment in both simulation-based education and clinical placement. Students overestimated their clinical judgment when compared to the more experienced evaluator's assessment. Differences between students' scores and the evaluator's scores were larger when the evaluator's scores were low, indicating the presence of the Dunning-Kruger effect.

CONCLUSION

It is vital to acknowledge that student self-assessment alone may not be a reliable predictor of a student's clinical judgment. Students who had a lower level of clinical judgment were likely to be less aware that this was the case. For future practice and research, we recommend a combination of student self-assessment and evaluator assessment to provide a more realistic view of students' clinical judgment skills.

Clinical judgment in new nurse graduates: identifying the gaps

OBJECTIVES

Clinical judgment has been identified as a key component of clinical practice. We sought to measure the elements of clinical judgment in new nurse graduates to identify future educational interventions.

METHODS

Lasater's clinical judgment rubric was adapted and distributed to nurse preceptors at two significant health care systems in central Illinois.

RESULTS

One hundred and six surveys were returned and one hundred and five of those were included in the study. New nurse graduates were found to be the lowest ranking in ability to identify significant data and calm, confident responses.

CONCLUSIONS

The findings can guide nurse educators to create innovative, targeted educational interventions to improve students' ability to identify important pieces of data and respond to challenging situations in a self-assured manner.

IMPLICATIONS FOR INTERNATIONAL AUDIENCE

Identifying and addressing the gaps to improve students' clinical judgment may facilitate NCLEX success and entry to practice.

Factors influencing nursing students' continued success in a baccalaureate nursing program in Indonesia

Background

Holistic admission processes are needed to promote diversity in nursing students. Previous research had identified different variables related to the average grade point at the end of the first semester. There is a need to examine if those variables are associated with ongoing student success.

Objective

The purpose of this study was to analyze experience, attributes, and academic variables for an association with nursing student success. Student success was defined as being an active student at the end of the first year and at the end of the second year of a baccalaureate nursing program in Indonesia.

Methods

Binary logistic regression analysis was used to determine what relationship, if any, the variables had with student success, measured at the end of the first and second academic years. The data of 341 nursing students enrolled in August 2018 was analyzed.

Results

The variables accounted for 40.3% of the variance at the end of the first year and 24.3% of the variance at the end of the second year. There was a significant (p < .05) relationship between being enrolled at the end of the first year and 1) academic variables of first semester grade point average and the admission score of Raven's Advanced Progressive Matrices, and 2) attribute variables of reason for entering nursing and brief calling presence scale. A significant relationship was found between being enrolled at the end of the second year and the attribute variable of grit score. No variables had a strong correlation with other variables.

Conclusion

Holistic admission processes and promoting student success can create the future of the nursing workforce. Improving the diversity in admitted nursing students will enhance the diversity in the nursing workforce. To promote the success of all students, a variety of support interventions will need to be developed. As students' calling and grit may play a role in student success, a better understanding is needed. In addition, more research is needed to explore how developing calling and grit throughout the nursing program can impact student success.

Clinical judgement in nursing - An evolutionary concept analysis

AIMS

The aim of this concept analysis was to develop a contemporary operational definition of Clinical Judgement in nursing.

DESIGN

Concept analysis.

METHODS

Rodgers' evolutionary method of concept analysis. Throughout the study, the authors followed the SRQR checklist.

RESULTS

This concept analysis guided the development of an operational definition of clinical judgement, within the context of nursing, articulated as Clinical judgement is a reflective and reasoning process that draws upon all available data, is informed by an extensive knowledge base and results in the formation of a clinical conclusion.

CONCLUSION

The purpose of this concept analysis was to propose a detailed definition of clinical judgement in nursing, that reflected its theoretical base within today's contemporary healthcare system. Using Rodgers' evolutionary method of concept analysis, surrogate terms, attributes, antecedents and consequences were identified, and a contemporary definition was developed. No patient or public contribution was required to design or undertake this research.

Perceptions of final year nursing students transer of clinical judgement skills from simulation to clinical practice: A qualitative study

AIM

To explore final year nursing student's ability to transfer clinical judgement skills to the clinical practice setting following immersive simulation.

BACKGROUND

Clinical judgement is considered a fundamental skill for nurses to ensure safe, quality care is delivered. In undergraduate nursing education where students have limited clinical experience, simulation-based education is an important educational strategy for introducing and developing these skills. Simulation allows for students to be exposed to repeated experiences and emotional responses to varying clinical situations. Despite this, there is a paucity of literature relating to students' ability to transfer clinical judgement skills from the simulated environment into clinical practice.

DESIGN

A naturalistic philosophical approach informed data collection in this qualitative phase of a larger study.

METHODS

Data were collected from students and nurse educators using semi-structured interviews as well as from facilitated simulation debriefs. Data were thematically analysed.

RESULTS

Four themes were identified which related to student knowledge, self-awareness and the clinical context: Safely collecting the data; Understanding the data to safely make decisions; Emotional intelligence; and Role variation. Students and educators held similar views on many of these elements.

CONCLUSIONS

Questioning was identified as a key component of nursing students' clinical judgements. There were challenges in assessing students' ability to link theory to practice in the clinical setting, despite evidence of this occurring in the simulated setting. Simulation prepares students for practice by exposing them to new experiences and stressors and therefore an effective educational technique for developing clinical judgement skills in this cohort.

Developing Students' Clinical Reasoning Skills: A Faculty Guide

BACKGROUND

Safe patient care relies on the ability of nurses to make timely, sound clinical judgments, yet new nurse graduates are underprepared. Nurse educators must take action with teaching to develop students' clinical reasoning skills and ultimately their clinical judgment. One first step is to consider strategies that integrate clinical judgment and clinical reasoning skills into nursing curriculum.

METHOD

The literature was reviewed to uncover what is known about teaching strategies that intentionally teach clinical reasoning skills and are focused on the development of students' clinical judgment.

RESULTS

Although not exhaustive, this guide for faculty discusses first steps when considering integrating clinical reasoning and judgment into nursing curriculum, presents teaching strategies, and provides ideas for implementation within nursing curriculum.

CONCLUSION

Teaching clinical reasoning skills, using a framework, and incorporating teaching strategies such as concept-learning, high-order questioning, and reflection focused on developing clinical reasoning skills may prove useful in developing students' clinical judgment. [J Nurs Educ. 2021;60(9):485-493.].

Illness scripts in nursing: Directed content analysis

Aims

To explore the possible extension of the illness script theory used in medicine to the nursing context.

Design

A qualitative interview study.

Methods

The study was conducted between September 2019 and March 2020. Expert nurses were asked to think aloud about 20 patient problems in nursing. A directed content analysis approach including quantitative data processing was used to analyse the transcribed data.

Results

Through the analysis of 3912 statements, scripts were identified and a nursing script model is proposed; the medical illness script, including enabling conditions, fault and consequences, is extended with management, boundary, impact, occurrence and explicative statements. Nurses often used explicative statements when pathophysiological causes are absent or unknown. To explore the applicability of Illness script theory we analysed scripts’ richness and maturity with descriptive statistics. Expert nurses, like medical experts, had rich knowledge of consequences, explicative statements and management of familiar patient problems.

Conclusion

The knowledge of expert nurses about patient problems can be described in scripts; the components of medical illness scripts are also relevant in nursing. We propose to extend the original illness script concept with management, explicative statements, boundary, impact and occurrence, to enlarge the applicability of illness scripts in the nursing domain.

Impact

Illness scripts guide clinical reasoning in patient care. Insights into illness scripts of nursing experts is a necessary first step to develop goals or guidelines for student nurses’ development of clinical reasoning. It might lay the groundwork for future educational strategies.

Development of a Clinical Judgment Scale for Japanese Nurses

BACKGROUND

The purpose of this study was to develop a scale to assess the clinical judgment of nurses based on the clinical judgment process.

METHOD

Based on a qualitative analysis of interviews with specialized and certified nurses and extant literature, a scale comprising 44 question items was created. A questionnaire survey was conducted with 1,444 nurses working in 28 general hospitals, psychiatric wards, cardiac care units, and intensive care units in Japan.

RESULTS

Valid responses were obtained from 610 nurses. Exploratory factor analysis was performed on the 23 items extracted by item analysis, and two factors, "theoretical and practical reasoning" and "grasping the condition by observation," were extracted. Confirmatory factor analysis revealed the fit of the model. Cronbach's alpha confidence factor was 0.943 for the first factor and 0.924 for the second factor.

CONCLUSION

These results support the factor validity and reliability of the clinical judgment scale. [J Contin Educ Nurs. 2021;52(8):383-391.].

The epistemic roles of clinical expertise: An empirical study of how Swedish healthcare professionals understand proven experience

Clinical expertise has since 1891 a Swedish counterpart in proven experience. This study aims to increase our understanding of clinicians' views of their professional expertise, both as a source or body of knowledge and as a skill or quality. We examine how Swedish healthcare personnel view their expertise as captured by the (legally and culturally relevant) Swedish concept of "proven experience," through a survey administered to a simple random sample of Swedish physicians and nurses (2018, n = 560). This study is the first empirical attempt to analyse the notion of proven experience as it is understood by Swedish physicians and nurses. Using statistical techniques for data dimensionality reduction (confirmatory factor analysis and multidimensional scaling), the study provides evidence that the proven experience concept is multidimensional and that a model consisting of three dimensions-for brevity referred to as "test/evidence", "practice", and "being an experienced/competent person"-describes the survey responses well. In addition, our results cannot corroborate the widely held assumption in evidence-based medicine that an important component of clinical expertise consists of experience of patients' preferences.

Exploratory Factor Analysis of the Indonesian Version of the Clinical Learning Environment, Supervision, and Nurse Teacher Scale (CLES + T)

BACKGROUND AND PURPOSE

The purpose of this article is to describe an evaluation of psychometric properties of the Indonesian version of the Clinical Learning Environment, Supervision, and Nurse Teacher (CLES + T) scale, a scale that measures nursing students' perceptions of their clinical learning environment.

METHODS

The CLES + T was completed by 292 nursing students. Inter-item correlations, exploratory factor analysis, Cronbach's alpha, and evidence of validity were used to examine reliability and validity.

RESULTS

Four factors were extracted that explained 58% of the variance. Cronbach alphas ranged from .86-.95. Wording to describe different titles of supervisors was unclear to some of the participants.

CONCLUSION

The Indonesian version of the CLES + T is a reliable version. More research is needed to clarify some of the wording.

Predictors of Nursing Clinical Judgment in Simulation

ABSTRACT

This was a pilot study of novice and expert nurses participating in a simulation to determine the predictors of clinical judgment. Covariates included age, nursing experience, simulation experience, and six measures of pupil dilation as a measure of stress with scores on the Lasater Clinical Judgment Rubric as the dependent variable. A stepwise linear regression found years of RN experience was the only predictor of better clinical judgment. Despite evidence of stress, only years as a nurse was a statistically significant predictor.

Level of clinical reasoning in intermediate nursing students explained by education year and days of internships per healthcare branches: A cross - sectional study

BACKGROUND

Due to changes in health care nurses are achieving more responsibilities. Globally nurses are trained at different educational levels to become registered nurses. All nurses should be able to implement clinical reasoning in chronic and acute patient care. There is uncertainty in health care institutes about the level of performance of clinical reasoning in the intermediate nurses.

OBJECTIVES

This cross-sectional study aimed to assess the level of clinical reasoning in intermediate nursing students in different education years. Furthermore, we explored whether the level of clinical reasoning can be explained by years of education and numbers of internship days in different healthcare settings.

DESIGN, SETTING AND PARTICIPANTS

All second, third and fourth year (n = 151) nursing students of one nursing school in the Netherlands were invited to participate in this study. Levels of clinical reasoning were assessed using the Dutch Lasater Clinical Judgment Rubric (D - LCJR).

METHODS

Twelve experienced nurses assessed the students during two days at the beginning of their education year in an educational simulation setting. Following the assessment protocol, the Rubric was scored in an interview after the students saw their patient.

RESULTS

We assessed 119 students. Fourth-year students scored on a significant higher level of clinical reasoning compared to the second - and third-year students (p < 0.001). Forty five percent of them reached an accomplished level of clinical reasoning. Second- and third-year students scored similar in their level of clinical reasoning (p = 0.61). In addition to education year an internship in the hospital care also explained the variation in level of clinical reasoning. Together they explained 38% (p < 0.001).

CONCLUSIONS

Intermediate nursing students were successfully assessed on their level of clinical reasoning in an education environment. The level of clinical reasoning could be explained by education year and number of days internship in the hospital care.

Effects of a transformative learning theory based debriefing in simulation: A randomized trial

Debriefing, based on reflection, is imperative in simulation. Mezirow's transformative learning theory (TLT) uses critical reflection in providing care to patients, which involves clinical judgment in nursing. The aim of this study was to compare the effects of TLT-versus a non-TLT-based debriefing protocol on knowledge, problem-solving process, critical thinking disposition, and clinical judgment in nursing students. A randomized controlled trial was performed. Fifty-six junior nursing students were assigned to the TLT (n = 26) and the control (n = 30) groups in South Korea. Debriefing protocols based on Mezirow's TLT for the experimental group and gather-analyze-summarize-based debriefing for the control group were used for four weeks. Scores of the TLT group were significantly higher than those of the control group in the problem-solving process, critical thinking disposition, and clinical judgment of reflection. We identified the main effects of group, time, and time-by-group interaction for clinical judgment (noticing, interpreting, and responding), except for knowledge between the two groups. The TLT debriefing approach in simulation can be tailored to improve problem-solving, critical thinking, and clinical judgment outcomes, which are vital to nursing education related to the provision of care to patients.

Guided reflective writing as a teaching strategy to develop nursing student clinical judgment

BACKGROUND

Nurse educators need strategies to help develop nursing students' clinical judgment skills to practice safely. Guided reflective writing is an active learning strategy that can increase learning and promote clinical judgment in patient care.

PURPOSE

The purpose of this qualitative descriptive study, guided by Tanner's Evidence Based Clinical Judgment Model, was to examine nursing student and faculty perspectives of the benefits and challenges of guided reflective writing for clinical judgment development following clinical experiences.

METHOD

Junior- and senior-level students participated in an open-ended survey regarding their experience of the guided reflective writing assignment postclinical. A focus group gained faculty perspectives of the assignment.

RESULTS

A final theme for each student group was developed: (1) organizes basic nursing care (Junior One students) and (2) sense of wholeness (Senior Two students). Progression in clinical judgment from Junior One to Senior Two students was noted. Faculty concurred with students' perspectives with their final theme, encourages deep thinking.

CONCLUSION

The results supported guided written reflection and clinical judgment development as key components to enhancing students' knowledge and preparation for complex nursing care. Guided reflective writing can be used as a reflection activity for clinical judgment development in a variety of settings including hospital, simulation, case studies, or virtual simulation.

Transitioning from direct care to virtual clinical experiences during the COVID-19 pandemic

When the COVID-19 pandemic forced university campuses and healthcare agencies to temporarily suspend both undergraduate and graduate direct care educational experiences, nursing programs had to formulate alternative plans to facilitate clinical learning. Texas Woman's University used this opportunity to assemble a faculty group tasked with creating a set of college-wide guidelines for virtual simulation use as a substitution for traditional face-to-face clinical. The process included completing a needs assessment of both undergraduate and graduate level programs across three campuses and identifying regulatory requirements and limitations for clinical experiences. The task force utilized the information gathered to develop evidence-based recommendations for simulation hour equivalence ratios and compiled a list of virtual activities and products faculty could use to complete clinical experiences. Undergraduate and graduate student surveys were conducted to determine the effectiveness of the transition to virtual clinical experiences. Overall, the majority of survey results were positive regarding virtual simulation experiences providing students with valuable opportunities to enhance their learning. Negative comments regarding the impact of COVID-19 on a personal level included issues involving internet access and web conferencing logistics, lack of motivation to study, family difficulties, and faculty inexperience teaching in an online environment. Undergraduate pre-licensure students were provided with opportunities to successfully complete all remaining required clinical hours virtually, while graduate students were allowed to complete non-direct care hours as applicable using virtual clinical experiences.

Educational intervention with serial album about pregnant women positioning for spinal anesthesia: randomized clinical trial

OBJECTIVE

To evaluate effectiveness of using educational intervention serial album to positioning pregnant women for spinal anesthesia.

METHOD

Randomized clinical trial with 90 women casually assigned to control (CG) and intervention group (IG), in a maternity hospital located in Northeast region of Brazil. The primary endpoint was "achieve correct positioning to perform spinal anesthesia"; and secondary, "how number of spinal cord puncture attempts". Effectiveness was verified using the chi-square test, Fisher's exact test and likelihood ratio.

RESULTS

The positioning was correct in 37 women in each group. There was an association between women in control group remaining still, relaxing shoulders and flexing the spine; and women in intervention group should remain still and relax the shoulders; furthermore there was a statistical association achieved by correct positioning and the number of attempts to access the lumbar puncture.

CONCLUSION

Educational intervention with serial album was effective and contributed to immobility and positioning of pregnant women. Brazilian Registry of Clinical Trials (RBR-3Z7SRD).

Clinical judgment skills among junior-level nursing students enrolled in adult health nursing courses: Errors and risk level classification

As the acuity of patients increases, so does the requirement for nurses who are capable of making proper clinical judgment for safe and quality patients' care. Assessment of students' clinical judgment at different stages of their nursing program is thus required. This descriptive cross-sectional study assessed the clinical judgment of 55 junior nursing students using a questionnaire that required participants to rate the severity and perceived risk and identify factors leading to errors described in four vignettes. Participants' perceptions of the impact of the errors described in the four vignettes differed. However, satisfactory agreement on error risk was evident (the highest rating ranged from 36% to 53.6%). Lack of clinical knowledge and experience and excessive workload were the most commonly identified contributory factors. Many of the junior nursing students in the study showed capability for critical analysis and classifications of error, risks, and associated factors. Based on current study results on error classification, associated risk and potential contributors the overall agreement of the students was moderate. Therefore, there is a need to increase efforts to impart higher clinical judgment skills to students enrolled in nursing education, for which regular longitudinal assessment is required.

The Realities of Collaboration: An Academic and Practice Partnership in Simulation Education With Nurse Residents

This article details the collaborative effort between a team of academic nurse educators with educators in a practice setting in the planning and implementation of a simulation-focused study to develop clinical judgment and clinical competency among new-to-practice nurses enrolled in a nurse residency program. Competing priorities between achieving the aims of the study and initiatives within the healthcare system are detailed, and suggestions for future joint research-focused efforts between academic and practice-based educators are offered.

Nurse Educators' Guide to Clinical Judgment: A Review of Conceptualization, Measurement, and Development

AIM

The purpose of this article is to define clinical judgment, examine valid and reliable instruments to measure the construct, review established strategies by which to develop it, and propose key future nursing education research priorities in clinical judgment.

BACKGROUND

A pressing interest in prelicensure nursing students' clinical judgment development has emerged in response to the National Council of State Boards of Nursing project Next Generation NCLEX.

METHOD

Sequential literature reviews uncovered six instruments that measure clinical judgment and 24 studies that demonstrate the effects of high-fidelity simulation on clinical judgment in prelicensure learners.

RESULTS

Six themes emerged: number of simulation-based experience exposures, specific nursing specialty simulations, debriefing and its effect on clinical judgment, assessment, clinical decision-making, and reflection.

CONCLUSION

Based on these results, key future research priorities investigating the effects of interprofessional simulation and simulation in the classroom were identified.

Clinical judgment and diagnostic reasoning of nursing students in clinical simulation

ABSTRACT Objectives: to determine the degree of association between clinical judgment and diagnostic reasoning of nursing students in clinical simulation. Methods: this is a correlational research design using a quantitative approach. The sample consisted of 41 nursing students who assisted a patient with vaso-occlusive crisis in a high-fidelity clinical simulation setting. The instruments used included the Lasater Clinical Judgment Rubric - Brazilian Version and the Diagnostic Thinking Inventory. Results: clinical judgment was associated with diagnostic reasoning (r=0.313; p=0.046), as well as the “noticing” aspect of clinical judgment with diagnostic reasoning (r=0.312; p=0.047). Conclusions: the results show that skills to interpret patient data are associated with diagnostic reasoning skills. Teaching clinical judgment skills is necessary to develop the diagnostic reasoning of nursing students.

Nurse Preceptor Role in New Graduate Nurses' Transition to Practice

The transition to practice period is a challenging and demanding time for new graduate nurses. Leaving the structured environment of nursing school and entering professional practice can cause reality and transition shock for the new nurse resulting in unsafe patient care, as well as intention to leave their position or the profession. Successful transition to practice depends on the new nurse building confidence and gaining essential clinical reasoning abilities while orienting to their role. In critical care settings, patient care is more complex and fast-paced, which adds another dimension of overall stress to the new graduate. Structured orientation programs with trained preceptors have been found to be the most successful means of preparing new graduate nurses for clinical practice. Ensuring preceptors are provided with education related to the development of clinical reasoning is essential to successfully assist new nurses in their transition to practice. Safe and effective patient care, especially in the critical care unit, is dependent upon having nurses who are well prepared for their role through being provided guidance and support from trained preceptors.

Building Scholarship for Evidence-Based Practice in Undergraduate Nursing Students

Journal clubs were utilized in an undergraduate nursing research course to achieve scholarship for evidence-based practice. Journal club members learned to critically appraise an assigned nursing research article by identifying the clinical problem, practicing literature search skills, and determining the research design and level of evidence. They also critically appraised the data collection methods, the sample size, and study outcomes and translated findings to practice. Over the semester, journal club members gained confidence in critically appraising research articles, came to appreciate the research process, and learned how nursing research informs evidence-based practice.

New Graduate Nurse Experiences in Clinical Judgment: What Academic and Practice Educators Need to Know

AIM

The aim of the study was to determine if use of a structured reflection exercise using a clinical judgment framework would result in more practice-ready new graduate nurses (NGNs).

BACKGROUND

Clinical judgment is a critical skill for all nurses, yet it is identified as a deficit in NGNs.

METHOD

Seventy-four NGNs in two groups participated in this mixed-methods study in their first year in practice. Scores from two quantitative measures were collected for all participants. The Lasater Clinical Judgment Rubric framed the structured intervention.

RESULTS

Although the quantitative data showed no significant differences between the groups, use of the reflection exercise indicated a positive impact on NGNs. Qualitative data revealed four themes that present challenges for preparation of NGNs: enhancing communication, finding interprofessional support, responding to complexity of care, and appreciating the role of the nurse.

CONCLUSION

Implications provide guidance for academic and practice educators to smooth the transition into practice.

Debriefing evaluation in nursing clinical simulation: a cross-sectional study

ABSTRACT Objective: Evaluate the contribution of debriefing after clinical simulations for nursing students. Method: Quantitative study, conducted with 35 nursing students who participated in five clinical simulation scenarios with planned debriefings based on the model of the National League Nursing/Jeffries Simulation Theory. After the fifth scenario, students answered the Debriefing Evaluation Scale associated with the Simulation. Results: The items evaluated involved the psychosocial, cognitive, and affective values, and within a scale from one to five, the highest mean was found in cognitive value with 4.23 (±0.56) points, then in psychosocial value with 3.77 (±0.53), and finally in affective value with 3.71 (±0.63) points. Conclusion: The debriefing conducted after the clinical simulation scenarios was a reflective exercise that contributed to the student integrating multiple knowledges in affective, cognitive and psychosocial values, and thus develop the competencies required.

[A Comparative Study on Learning Outcomes according to the Integration Sequences of S-PBL in Nursing Students: Randomized Crossover Design]

PURPOSE

This study aimed to compare the effects of simulation integrated with problem based learning (S-PBL) according to the sequences of problem-based learning (PBL) and high fidelity simulation training (HFS) on knowledge, clinical performance, clinical judgment, self-confidence, and satisfaction in fourth-grade nursing students.

METHODS

In this randomized crossover design study, four S-PBLs on medical-surgical nursing were applied alternatively to two randomly-assigned groups of 26 senior nursing students for 8 weeks. The collected data were analyzed using an independent t-test.

RESULTS

The method of administering PBL prior to HFS led to significantly higher scores on knowledge (t=2.28, p=.025) as compared to the method of administering HFS prior to PBL. However, the latter method led to significantly higher scores on clinical performance (t=-6.49, p<.001) and clinical judgment (t=-4.71, p<.001) as compared to the method of administering PBL prior to HFS. There were no differences in the effect of the two methods on self-confidence (t=1.53, p=.128) and satisfaction (t=1.28, p=.202).

CONCLUSION

The integration sequences of S-PBL was associated with different learning outcomes. Therefore, when implementing S-PBL, it is necessary to consider the educational goal to executes an appropriate sequence of integration.

Teaching Clinical Reasoning Piece by Piece: A Clinical Reasoning Concept-Based Learning Method

BACKGROUND

Recent discourse generates a more thorough understanding of what clinical reasoning entails. Although numerous strategies prioritize clinical reasoning development, teaching and evaluating the thinking involved in clinical reasoning remains a struggle for nurse educators, particularly regarding clinical education.

METHOD

In response, the author developed a concept-based clinical reasoning teaching method with weekly themes, lessons, and learning activities adapted from Tanner's clinical judgment model and Lasater's Clinical Judgment Rubric.

RESULTS

The method offers an organized, consistent approach to teaching and learning clinical reasoning, with multiple opportunities for student reflection, instructor guidance, and discussing clinical reasoning concepts. Clinical education became transformed for both the nurse educator and nursing students as clinical reasoning became a visible part of students' budding nursing practice.

CONCLUSION

Nurse faculty must ensure future nurses are prepared to think-inaction. The clinical reasoning teaching method offers one potential solution. [J Nurs Educ. 2018;57(12):727-735.].

Practice and effectiveness of "nursing case-based learning" course on nursing student's critical thinking ability: A comparative study

BACKGROUND

Case-based Learning was an effective and highly efficient teaching approach that was extensively applied in education systems across a variety of countries. Critical thinking ability is an important indicator for access the study ability for baccalaureate nursing education.

OBJECTIVES

The study aimed to explore the effect of "nursing case-based learning" course on the critical thinking ability of nursing student.

PARTICIPANTS

A total of 80 students who were in Junior were included in this study. The experimental group included 40 students who selected "nursing case-based learning" course. The control group included 40 students who selected the traditional teaching course.

METHODS

The critical thinking disposition inventory (CTDI-CV) was used to evaluate the effects of the critical thinking abilities during the 1st week (pre-test), the 9th week (mid-test), and the 18th week (post-test).

RESULTS

There are no statistically significant differences between two groups in the pre-test thinking abilities (P > 0.05). After nine weeks, the critical thinking abilities of experimental group were significantly higher than control group (P < 0.05). Three obtained time-points had statistically significant differences of control and experimental group (P < 0.05).

CONCLUSION

The "nursing case-based learning" was an effective course to develop the critical thinking abilities of nursing students. Strict instructional design was the guarantee for the smooth implementation of "nursing case-based learning" course.

Improving clinical judgment by simulation: a randomized trial and validation of the Lasater clinical judgment rubric in Chinese

BACKGROUND

The development and assessment of clinical judgment ability are essential in nursing education. The Lasater Clinical Judgment Rubric (LCJR) was shown to be valid in evaluating nursing students' learning outcomes and skills in western cultures but has not been validated in mainland China. This study aimed to compare a simulation-teaching model with a traditional teaching method in enhancing the clinical judgment ability of nursing undergraduate students and to validate the Chinese version of the Lasater Clinical Judgment Rubric (C-LCJR).

METHODS

Four classes of nursing students (n = 157) at Hubei University of Chinese Medicine, China, were randomly assigned to two control and two experimental classes. The experimental classes were taught using simulation teaching with standardized patients, while the control classes were taught using traditional teaching methods. At the end of the experiment, students in both kinds of classes evaluated their clinical judgment using the C-LCJR. Teachers also rated the students but without knowing who had received the simulation teaching. Confirmatory factor analysis and a Multiple Indicators Multiple Causes (MIMIC) model with Bayesian estimation was fit to the rating data to investigate measurement properties and experimental effects.

RESULTS

Compared to the control classes, students in the experimental classes performed better in all subdomains of C-LCJR (noticing, interpreting, responding, and reflecting). The measurement properties of the C-LCJR were found to be satisfactory with high factor loadings and reliabilities and no bias from age, gender, and raters.

CONCLUSIONS

The simulation teaching model is more effective than the traditional (non-simulation-based) teaching method in improving clinical judgment of Chinese nursing students. The C-LCJR is a valid and reliable instrument for measuring clinical judgment in nursing students in China.

Simulation for Clinical Preparedness in Pediatric Emergencies: A Pilot Study

Positive outcomes for pediatric in-hospital cardiopulmonary arrest remain low with little change in mortality rates. Infrequently used clinical knowledge and skills decline quickly, contributing to poor quality of resuscitation. The aim of this pilot study exploring the outcomes of repeated pediatric mock code simulations with structured debriefing demonstrated statistically significant differences in participants' knowledge of pediatric emergencies, with no significant decline in resuscitation skills. This provides an evidence-based approach for professional development educators working with nurses on pediatric emergencies.

Psychometric Evaluation of a Rubric to Assess Basic Performance During Simulation in Nursing

AIM

This study was conducted to evaluate the psychometric properties of a rubric to assess nursing student performance in medium- and low-fidelity simulation.

METHOD

A psychometric study was carried out. Content validity was explored by a group of experts. Internal consistency was determined by means of Cronbach's coefficient alpha. Interrater agreement and the level of concordance were established by the kappa coefficient and intraclass correlation index.

RESULTS

The relevance of the dimensions and the definition of each category scored higher than 3.25 on a Likert-type scale (maximum value of 4); content validity ratio values were close to +1. The kappa index was above 0.61 (p < .001) in all dimensions, thereby indicating a good level of interrater agreement; the intraclass correlation index showed values above .82 (p < .001).

CONCLUSION

The rubric appears to be psychometrically sound, thus supporting its reliability.