Evaluation of Clinical Judgment in Prelicensure Nursing Students

Nursing Students' Perception of Just Culture and Development of Self-Confidence With Clinical Judgment: A Scoping Review

AIM

The aim of this study was to determine what is currently known about just culture's impact on nursing students' development of self-confidence with clinical judgment.

BACKGROUND

Graduates of nursing programs must execute sound nursing judgment to provide safe client care.

METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guided the scoping review. The review elicited 1,411 sources and included 18 data sources.

RESULTS

Just culture was found to provide elements of trust, fairness, and psychological safety needed by nursing students to be self-confident in learning and executing clinical judgments that promote client safety.

CONCLUSION

Just culture promotes client safety in nursing education. Limited information exists on just culture's influence on student self-confidence with clinical judgment; more research is therefore required.

Current practices for assessing clinical judgment in nursing students and new graduates: A scoping review

OBJECTIVE

To map current assessment practices for learning outcomes related to nurses' clinical judgment from undergraduate education to entry to practice.

DESIGN

Scoping review using the Joanna Briggs Institute guidelines and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

DATA SOURCES

Electronic databases-Cumulative Index of Nursing and Allied Health Literature (CINAHL Complete; EBSCOhost), EMBASE (Ovid), MEDLINE (Ovid), PsycINFO (Ovid), and Web of Science (Social Sciences Citation Index, Citation Index Expanded)-using a combination of descriptors and keywords related to nursing students, newly graduated nurses, clinical judgment and related terms (e.g., critical thinking, clinical reasoning, clinical decision-making, and problem-solving), and assessment.

METHODS

Two reviewers independently extracted study characteristics and, for each outcome relevant to clinical judgment, the concept, definition and framework, assessment tool, and the number and schedule of assessments. Data were synthesized narratively and using descriptive statistics.

RESULTS

Most of the 52 reviewed studies examined the outcome of a discrete educational intervention (76.9 %) in academic settings (78.8 %). Only six studies (11.5 %) involved newly graduated nurses. Clinical judgment (34.6 %), critical thinking (26.9 %), and clinical reasoning (9.6 %) were the three most frequent concepts. Three assessment tools were used in more than one study: the Lasater Clinical Judgment Rubric (n = 22, 42.3 %), the California Critical Thinking Skills Test (n = 9, 17.3 %), and the Health Science Reasoning Test (n = 2, 3.8 %). Eleven studies (21.2 %) used assessment tools designed for the study.

CONCLUSION

In addition to a disparate understanding of underlying concepts, there are minimal published studies on the assessment of nursing students and nurses' clinical judgment, especially for longitudinal assessment from education to clinical practice. Although there is some existing research on this topic, further studies are necessary to establish valid and reliable clinical competency assessment methods that effectively integrate clinical judgment in clinical situations at relevant time points.

The Effects of Low-Fidelity Simulation on Students' Perceived Abilities to Build Therapeutic Relationships

BACKGROUND

The combination of nursing student anxiety toward patients with mental health conditions, along with their unpreparedness for exercising active listening, empathy, and self-awareness in clinical situations, creates a barrier to achieving therapeutic nurse- patient relationships.

METHOD

A quantitative quasiexperimental study with a one-group pretest-posttest design was used to determine whether a low-fidelity communication simulation laboratory would decrease nursing students' perceived anxiety levels toward mental health patients and increase students' perceived empathy, self-awareness, and active listening levels.

RESULTS

After completing the communication simulation laboratory, students' anxiety decreased significantly (p < .001) and active listening increased significantly (p < .001); empathy and self-awareness levels were relatively unchanged.

CONCLUSION

Using a communication simulation laboratory effectively decreased nursing students' perceived anxiety levels toward patients and improved their perceived active listening skills. The findings of the study support the use of low-fidelity simulations to prepare students for psychiatric nursing clinical practice. [J Nurs Educ. 2023;62(10):575-579.].

A protocol for a scoping review of the use of mental simulation and full-scale simulation in practising healthcare decision-making skills of undergraduate nursing students

AIM

This scoping review aims to explore the effect of FSS and mental simulation on the decision-making skills of nursing students.

BACKGROUND

Full-scale simulation (FSS) has been the most used simulation modality in nursing education due to its applicability to enhance both technical and non-technical skills. However, FSS can be excessively costly and other factors such as technophobia and lack of trained staff and support make FSS less accessible, especially for nursing education. Therefore, a novel mental simulation that is interactive and supported by visual elements can be a substitute for FSS, at least for some of the skills, such as clinical decision-making. Reviews comparing the effectiveness of FSS and mental simulation on decision-making skills in nursing students are lacking. Further knowledge on the effectiveness of these two modalities on decision-making skills for nursing students is needed to inform the nursing education curriculum and to decide between the two modalities.

DESIGN

This protocol adheres to the guidelines outlined in the PRISMA extension for scoping reviews (PRISMA-scr) checklist.

METHOD

The methodological framework for scoping reviews will be followed for this scoping review. Scopus, EBSCOhost the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE and for the grey literature ERIC and BASE will be searched for related studies. The search will be limited to January 2008 and April 2023 (up-to-date) and English. A detailed search strategy was developed with an experienced research information manager and this strategy will be adapted to each database. A single screening will be performed by an author who will screen all abstracts and titles and full-text publications. After the study selection step of the framework, the data from the included studies will be charted using a data extraction form. The data will be synthesised by comparing the effect of FSS and mental simulation on decision-making skills.

CONCLUSION

A synopsis of the publication on FSS and mental simulation on nurse students' decision-making skills will be useful for stakeholders when choosing between two modalities to deliver decision-making skills to nursing students and also help to inform the nursing education and simulation practice.

SCOPING REVIEW REGISTRATION

Protocols.io (doi: 10.17504/protocols.io.e6nvw57y7vmk/v1).

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.

Nursing Students' Perceptions of Learning With NGN-Style Case Studies

BACKGROUND

The National Council of State Boards of Nursing (NCSBN) developed Next Generation NCLEX (NGN) case studies and new test items, based on the NCSBN Clinical Judgment Measurement Model, to assess nurse graduates' clinical judgment and decision-making ability.

PURPOSE

This study investigated nursing students' perceptions of learning with NGN-style case studies.

METHODS

A mixed-methods approach collected nursing students' perceptions in a 6-item survey.

RESULTS

Overall respondents agreed that the case studies were helpful in learning (n = 45; 90%), applying course concepts (n = 46; 92%), learning clinical judgment (n = 46, 92%), and promoting active learning (n = 43, 86%), and were a useful learning strategy (n = 48, 96%). Themes identified in narrative comments were critical thinking, real-life application, and a learning tool.

CONCLUSIONS

NGN-style case studies were useful as an active learning strategy to promote clinical judgment and real-life application of course concepts.

Using Simulation to Develop Clinical Judgment in Undergraduate Nursing Students

The National Council of State Boards of Nursing plans to update the National Council Licensure Exam for nursing graduates to better measure clinical judgment. It is important that schools of nursing provide opportunities for nursing students to practice and develop clinical judgment skills. Simulation offers nursing students opportunities to use clinical reasoning and clinical judgment to care for patients in a safe environment The purpose of this study was to evaluate an unfolding case study using high-fidelity simulation to develop nursing students' clinical judgment skills across three practice settings: primary care office, acute care hospital, and home healthcare. This was a mixed-method, posttest study design with a convenience sample of 91 nursing students using the Lasater Clinical Judgment Rubric (LCJR) and survey questions. The posttest analysis mean of the LCJR subgroups revealed students felt accomplished following the intervention. Four themes emerged from content analysis of the qualitative data: 1.) increased knowledge of management of diabetes in various clinical settings, 2.) using clinical judgment/critical thinking in the home care setting, 3.) being able to self-reflect on actions, and 4.) a desire for more simulation experiences in the home healthcare setting. The results of the LCJR indicated that students felt accomplished after the simulation experience. This outcome was also evident in the qualitative data, indicating that students felt more confident in managing the care of a patient with a chronic illness using clinical judgment skills in various clinical settings.

Effect of Manikin and Virtual Simulation on Clinical Judgment

BACKGROUND

Evidence suggests competency in clinical judgment may be lacking in new graduate nurses. Graduates from accelerated baccalaureate nursing (ABSN) programs have even less time to develop clinical judgment competency. Various simulation modalities, including high-fidelity manikin and virtual reality, have been used to develop clinical judgment in prelicensure students. However, the outcomes of these simulation modalities on clinical judgment in ABSN students is not well understood.

METHOD

An integrative literature review was conducted using five databases with primary research that examined the effect of manikin or virtual simulation on clinical judgment in BSN students.

RESULTS

Fourteen studies were included in this review. The findings were organized using Tanner's Clinical Judgment Model.

CONCLUSION

Findings from this review were mixed, with a lack of evidence comparing the two modalities. Future research should include comparison studies aimed at examining the effects of these modalities with ABSN students. [J Nurs Educ. 2022;61(12):693-699.].

Virtual Health Assessment Laboratory Course Delivery and Nursing Student Clinical Judgment: A Mixed-Methods Exploratory Study

BACKGROUND

It is essential to explore virtual learning experiences to identify their impact on nursing students' learning.

PURPOSE

The purpose of this study was to investigate the relationship between the virtual delivery of a health assessment laboratory course and nursing students' clinical judgment.

METHODS

Using a mixed-methods explanatory sequential design, the investigators appraised the final laboratory examinations of both in-person and virtual delivery cohorts using the Lasater Clinical Judgment Rubric (LCJR) and then interviewed faculty members.

RESULTS

The LCJR total mean scores (mean = 10.64) and mean scores for Effective Noticing (mean = 3.48) were higher for the virtual delivery students. The faculty reported that virtual delivery advances students' critical appraisal skills related to subjective assessment but advocated for in-person delivery to develop physical examination techniques.

CONCLUSION

Although the mean clinical judgment scores were higher for the students whose course delivery was virtual, in-person experiences are necessary to develop psychomotor techniques to prepare students for clinical practice.

Evaluating the Clinical Reasoning of Student Health Professionals in Placement and Simulation Settings: A Systematic Review

(1) Background: Clinical reasoning is essential to the effective practice of autonomous health professionals and is, therefore, an essential capability to develop as students. This review aimed to systematically identify the tools available to health professional educators to evaluate students' attainment of clinical reasoning capabilities in clinical placement and simulation settings. (2) Methods: A systemic review of seven databases was undertaken. Peer-reviewed, English-language publications reporting studies that developed or tested relevant tools were included. Searches included multiple terms related to clinical reasoning and health disciplines. Data regarding each tool's conceptual basis and evaluated constructs were systematically extracted and analysed. (3) Results: Most of the 61 included papers evaluated students in medical and nursing disciplines, and over half reported on the Script Concordance Test or Lasater Clinical Judgement Rubric. A number of conceptual frameworks were referenced, though many papers did not reference any framework. (4) Conclusions: Overall, key outcomes highlighted an emphasis on diagnostic reasoning, as opposed to management reasoning. Tools were predominantly aligned with individual health disciplines and with limited cross-referencing within the field. Future research into clinical reasoning evaluation tools should build on and refer to existing approaches and consider contributions across professional disciplinary divides.

A Quantitative Research Study Protocol to Advance Simulation Science in Nursing Education

AIM

This article describes a quantitative simulation study protocol and identifies important methodological considerations for future high-level, rigorous quantitative simulation studies.

BACKGROUND

Quantitative simulation research studies have been found to be lacking in their conceptualization, study design, and measurement of outcomes, with small samples and lack of rigor in overall study methods.

METHOD

This protocol reflects research priorities of organizations that drive simulation science and nursing education, published standards of simulation best practice, and use of research methodology within and outside the simulation literature, which includes psychometrically sound instruments and outcomes of importance to cognitive and simulation science.

RESULTS

The protocol was a multisite, longitudinal study, guided by the integrative model of clinical judgment, with a high degree of intervention fidelity to measure the study outcomes of clinical judgment and clinical competence.

CONCLUSION

To advance simulation science, rigorous study protocols, reflective of the one described in this article, are needed.

An End-of-Life Communication Performance Rubric: Reliability Assessment

Nurse educators still struggle with teaching and assessing end-of-life communication skills. Many resources are available to assist in teaching end-of-life communication, but few tools exist to assess performance learning outcomes. Behavior evaluation tools must be user-friendly and provide beneficial student feedback. Quality end-of-life patient care and nursing job satisfaction depend on skillful communication. The purpose of this study was to evaluate the reliability of an end-of-life communication clinical simulation evaluation performance rubric. Moderate interrater consistency and agreement were found between 3 evaluators when assessing the same students. All simulation evaluators agreed that the performance rubric was user-friendly and provided rich feedback for students during simulation debriefing. The performance evaluation tool was moderately effective when evaluating end-of-life communication performance and appears as a worthy framework for other behavior evaluations.

Clinical judgment model-based nursing simulation scenario for patients with upper gastrointestinal bleeding: A mixed methods study

Assisting patients with upper gastrointestinal bleeding is a crucial role for nurses, and as future nurses, students should demonstrate sound clinical judgment. Well-structured, high-quality simulations are useful alternatives to prepare students for clinical practice. However, nursing simulation scenarios focused on enhancing clinical judgment in managing upper gastrointestinal bleeding are limited. This study aims to develop, apply, and evaluate an effective nursing simulation scenario for patients with upper gastrointestinal bleeding based on Tanner’s clinical judgment model using a mixed methods study design. A high-fidelity patient simulation was conducted among 80 undergraduate nursing students divided into a simulated control group (n = 39) and an experimental group (n = 41). Subsequent student performance evaluations used questionnaires and video recordings. After scenario simulations, the students showed a statistically significant increase in theoretical knowledge (p = 0.001) and clinical performance skills (p < 0.001), but there was no significant increase in self-confidence (p = 0.291). According to the video analysis, the “noticing” clinical judgment phase was the most frequently observed phase, while “reflection” was the least frequently observed phase. Additionally, “education” was the most frequently observed nursing domain, and “anxiety” was the least frequently observed domain. Although further simulation repetitions are required to reinforce students’ self-confidence when caring for patients with upper gastrointestinal bleeding, the scenario was deemed effective. Moreover, emphasis should be placed on developing various scenarios to strengthen students’ clinical judgment skills, especially “reflecting” and “emotional care.”

The Lasater Clinical Judgment Rubric: Implications for Evaluating Teaching Effectiveness

BACKGROUND

Concern with patient safety necessitates valid and reliable measures to evaluate clinical judgment. The purpose of this article is to describe how the Lasater Clinical Judgment Rubric (LCJR) has been used to evaluate the effectiveness of educational interventions to promote clinical judgment and its psychometric properties.

METHOD

Search terms included nurse, student, clinical judgment, and Lasater Clinical Judgment Rubric in Scopus, ERIC, and CINAHL with EBSCOhost databases. The final review included 20 studies.

RESULTS

Researchers reported alphas for total scales as .80 to .97, subscales as .89 to .93, and students' self-scored as .81 to .82. Themes were: Individual Versus Group Evaluations, Clinical Judgment Scenarios, and Adaptation for Nonobservation Activities.

CONCLUSION

Results of this review indicate that the LCJR can be used to evaluate clinical judgment, but educators need to consider inter- and intrarater reliability, individual versus group evaluation, clinical judgment scenarios, and adapting the rubric for nondirect observation activities. [J Nurs Educ. 2021;60(2):67-73.].

The effect of multiple exposures in scenario-based simulation-A mixed study systematic review

Aims

To examine the use and effects of multiple simulations in nursing education.

Design

A mixed study systematic review. Databases (CINAHL, Medline, PubMed, EMBASE, ERIC, Education source and Science Direct) were searched for studies published until April 2020.

Method

Researchers analysed the articles. Bias risk was evaluated using the Critical Appraisal Skills Programme and Cochrane Risk of Bias tool.

Results

In total, 27 studies were included and four themes identified. Students participated in multiple simulation sessions, over weeks to years, which included 1-4 scenarios in various nursing contexts. Simulations were used to prepare for, or partly replace, students' clinical practice. Learning was described in terms of knowledge, competence and confidence.

Conclusion

Multiple scenario-based simulation is a positive intervention that can be implemented in various courses during every academic year to promote nursing students' learning. Further longitudinal research is required, including randomized studies, with transparency regarding study design and instruments.

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.

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.

Satisfactory Completion of End-of-Course Outcomes Using Simulation

BACKGROUND

Simulation is replacing clinical hours in prelicensure nursing programs, and students must be evaluated to ensure that the end-of-course outcomes are met. The purpose of this study was to identify what an average score (or cutoff score) for high-fidelity simulation is for successful and satisfactory completion of end-of-course outcomes in a medical-surgical nursing course using the Lasater Clinical Judgment Rubric.

METHOD

A retrospective, descriptive, quantitative study was performed using a convenience sample of 143 RN diploma nursing students. Data were collected from 2013 to 2017.

RESULTS

A cutoff score of 28 was identified indicating satisfactory and successful completion of end-of-course outcomes in a medical-surgical nursing course.

CONCLUSION

Ensuring that students meet end-of-course outcomes and participating in simulated patient scenarios is essential in meeting board of nursing regulations. [J Nurs Educ. 2018;57(8):489-492.].