Evaluating the Clinical Judgment of Prelicensure Nursing Students in the Clinical Setting

Evaluating a Shared Reflective Practice to Develop Nursing Student Clinical Judgment

BACKGROUND

Self-reflection is a valuable method that nurse educators can use to develop clinical judgment skills among prelicensure nursing students. Little research exists on improving clinical judgment in second-degree nursing students in the clinical setting.

PURPOSE

To determine the implications of increasing clinical judgment skills in prelicensure nursing students using a shared structured reflection teaching innovation within a required baccalaureate clinical course.

METHODS

This educational innovation used qualitative descriptive methods to evaluate its effectiveness in the clinical setting among students in the final semester of an accelerated prelicensure nursing program.

RESULTS

Students reported increased accountability for their learning, a sense of intentionality with their nursing practice, and a deeper sense of community with their peers.

CONCLUSIONS

Shared reflective practices in the clinical setting show promise for increasing clinical judgment and supporting a competency-based curriculum.

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.].

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.

Ethics positions of nursing students in clinical decision-making

BACKGROUND

Ethics positions, consisting of the two fundamental dimensions of idealism and relativism, influence individuals' decision-making significantly. Particularly in an applied field such as nursing, the ethics positions of nurses can play a significant role in clinical decisions. Therefore, it is important to know the factors affecting the ethics positions of nurses in clinical decision-making.

AIM

The aim of the study is to examine the factors affecting the ethics positions of nursing students in clinical decision-making.

RESEARCH DESIGN

This is a two-phase sequential explanatory mixed methods study designed in accordance with the COREQ criteria. A participant Information Form and the Ethics Position Questionnaire were used to collect quantitative data. Qualitative data were obtained through focus group interviews.

ETHICAL CONSIDERATIONS

This study was conducted after receiving written permission from X University Ethics Board. Additionally, permission was obtained from the participating nursing faculty.

PARTICIPANTS

Among the fourth-year nursing students, 180 students participated in the quantitative phase and 30 students in the qualitative phase of the study.

RESULTS

The quantitative data analysis showed that the idealism sub-dimension mean scores of the participants were higher than the relativism sub-dimension mean scores. The analysis of the qualitative data resulted in four main themes that influence participants' ethics positions in clinical decision-making: (1) attitudes of role models in clinical practice (staff nurses/mentors/lecturers), (2) resources related to clinical practice (labs, hospitals/classrooms), (3) health system (hospital policies/school policies), and (4) personal differences (act with emotion/act with logic).

CONCLUSION

The results showed that the health system, role models in the clinic, personal differences, and skill-related resources affect the ethics positions of nursing students in clinical decision-making. In this regard, awareness can be raised by providing training to nursing students by academic instructors on ethics positions and the factors that are determined to affect ethics positions in clinical decision-making.

Clinical Judgment Development and Assessment in Clinical Nursing Education

BACKGROUND

There is a gap in evidence for effective clinical teaching strategies to promote nursing students' development of clinical judgment (CJ).

PURPOSE

This study examined the effect of active learning strategies (ALSs) during clinical postconference sessions on the CJ of undergraduate nursing students.

METHODS

This quasi-experimental study of ALSs or standard postconferences used the Lasater Clinical Judgment Rubric (LCJR) to rate CJ at 3 time points. All faculty members and students were trained on use of the LCJR. Ratings were done by both faculty and students.

RESULTS

All ratings of CJ improved over time ( P < .001). Ratings of CJ varied between the control and intervention groups.

CONCLUSIONS

The findings of this study contribute to knowledge regarding the effectiveness of clinical teaching strategies for CJ and preparation for entry to nursing practice.

Characteristics and processes of registered nurses' clinical reasoning and factors relating to the use of clinical reasoning in practice: a scoping review

OBJECTIVE

The objective of this review was to examine the characteristics and processes of clinical reasoning used by registered nurses in clinical practice, and to identify factors reported to relate to the use of clinical reasoning by registered nurses in clinical practice.

INTRODUCTION

Significant variability in the clinical reasoning of graduate registered nurses has been identified in research, with underdeveloped and unsafe clinical reasoning being linked to failure-to-rescue and sentinel events in the clinical setting. The identification of characteristics and processes of clinical reasoning, and factors relating to registered nurses' clinical reasoning when engaged in clinical practice, will increase understanding of the clinical reasoning requirements for undergraduate registered nurses and of potential factors that may affect their clinical reasoning.

INCLUSION CRITERIA

Studies including registered nurses who met the criteria for registered nurse registration in Australia and who used clinical reasoning to engage with health care consumers in all practice environments were eligible for inclusion.

METHODS

Eight databases were searched, with articles identified through CINAHL, MedNar, PubMed, Science Direct, ERIC, PsycINFO, Scopus, and ProQuest Dissertations and Theses. Database searches were conducted on December 31, 2020, and updated August 20, 2021, with primary qualitative and quantitative research studies in English from 2000 onwards considered for inclusion. Opinion papers, text, and reports were not included. Data were extracted based on the draft charting tool from the scoping review protocol, with results presented in tabular format and in a narrative summary.

RESULTS

The 29 qualitative and 5 quantitative research studies included in the scoping review utilized exploratory descriptive, descriptive rationalist, narrative, ethnography, correlational, observational, and grounded theory methodologies in their research designs. Observation, think-aloud sessions, questionnaires, surveys, interviews, and focus groups were used to collect data from the 1099 participants in 9 countries. Multiple concepts related to the characteristics (n=35) and processes (n=30) of clinical reasoning were detected in the research studies, with 5 categories identified: i) situation management, ii) data management, iii) interpreting, iv) implementing and evaluating, and v) professional practice, with an additional processes category identified (decision-making processes). The factors (n=26) reported to relate to clinical reasoning were categorized into environment of care, care requirements, professional practice, experience, knowledge, and decision-making processes. Connections between the various concepts were evident throughout the review.

CONCLUSIONS

The scoping review identified characteristics and processes of clinical reasoning, as well as factors reported to relate to clinical reasoning in all studies. The concepts that comprise the clinical reasoning of registered nurses in clinical practice must be considered in undergraduate registered nurse education. Registered nurses must complete their baccalaureate program with well-developed clinical reasoning to ensure safe clinical practice. Understanding the characteristics and processes of registered nurses' clinical reasoning in clinical practice, and the factors reported to relate to clinical reasoning, supports the creation of targeted resources for development and assessment of clinical reasoning.

Clinical learning opportunity in public academic hospitals: A concept analysis

BACKGROUND

Clinical learning opportunities (CLO) are vital educational encounters occurring in various clinical areas to provide the student nurses with clinical knowledge and experiences to develop their competencies for professional practice. However, CLO is a broad concept with varied characteristics that allow ambiguity, limiting its understanding and use. Its ambiguous nature leads to uncertainties and poor development of the required clinical attributes of successful theory to practice integration, higher-order thinking skills (HOTS) and clinical competencies.

AIM

The aim of the study was to explore and describe the conceptual meaning of CLO, have a clear understanding and insight into the concept and identify the antecedents and consequences for pragmatic purposes.

SETTING

The study took place in a public academic hospital in Gauteng.

METHODS

The eight steps of concept analysis by Walker and Avant were followed. Multiple data sources not limited to nursing were explored and critically analysed for the definitions, characteristics, nature and uses of CLO from different fields of study.

RESULTS

The defining attributes of CLO were identified, namely the context, antecedents, processes, consequences and outcomes. The context within which CLO occurs was dynamic, multidimensional, real-life healthcare settings; antecedents included planning of clinical placement, provision of learning outcomes and consideration of the cognitive level of the students. Engagement and active participation in collaborative, problem-based learning activities, community-based research and the use of emerging technologies were the processes identified. The outcomes were autonomous, confident, competent professional nurses with critical thinking, clinical reasoning, judgement, critical decision making and problem-solving skills.

CONCLUSION

A theoretical and operational definition of CLO was developed. The findings and results of concept analysis identified and specified the defining attributes of clinical learning opportunity. The findings can assist nurse educators, Clinical Education and Teaching Unit (CETU) personnel and operational managers to enhance CLO for student nurses to achieve their clinical learning goals and outcomes. The evaluation tools that may be adopted to assess the acquired clinical skills were also identified.

CONTRIBUTION

An increase in the existing body of knowledge in nursing education, considering that enhancing the CLO exposes students to various clinical experiences contributing to their development of clinical competencies to solve complex problems. The strategies to enhance the CLO will be developed, which may also provide vital information for policy development. Conceptualisation of the findings to nursing practice and quality patient care will be integrated into relevant literature.

A concept analysis of clinical judgment in undergraduate nursing students

AIM

To offer a clear understanding of the definition, attributes, antecedents, and consequences of undergraduate nursing students' clinical judgment in the nursing education context.

BACKGROUND

Clinical judgment is a concept with broad uses among healthcare professionals. Its definitions and attributes vary across contexts. There is no established understanding of clinical judgment in nursing students.

DESIGN

This concept analysis was performed using the eight steps of Walker and Avant's framework.

DATA SOURCES

A literature search was conducted using search engines and included peer-reviewed articles related to clinical judgment in nursing students.

RESULTS

Clinical judgment in nursing students was defined as the cognitive process exhibited via a nursing action by observation, patient assessment, interpreting, and prioritizing data that lead to responding using the appropriate nursing practice with the patient. Reflection was used to evaluate nursing students' clinical judgment to revise nursing practice. Antecedents included nursing education curriculum, student's knowledge, previous clinical experience, critical thinking, and clinical reasoning. The consequences of clinical judgment were clinical judgment ability, safe nursing practice, nursing care quality, and patient safety.

CONCLUSIONS

This concept analysis gives clear insights into the definition, attributes, antecedents, and consequences of undergraduate nursing student's clinical judgment.

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.

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.

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 Reasoning, Judgment, and Safe Medication Administration Practices in Senior Nursing Students

BACKGROUND AND PURPOSE

Medication errors occur at alarming rates. Safe medication administration practices require more than observing patient safety rights and psychomotor skills. The purpose of this study was to explore the relationships between clinical judgment skills and reasoning processes and safe medication practices in senior nursing students.

METHODS

Using a cross-sectional design, 29 students from 3 schools of nursing watched a video simulation of a nurse administering medications in a clinical setting. At predetermined times, reflections on the medication administration practices were journaled. Journals were scored for clinical reasoning processes and clinical judgment using the Clinical Judgment Rubric-Reflective Journal (CJR-RJ) and for medication administration best practices.

RESULTS

Students scored low on the CJR-RJ (mean [SD], 5.2 [1.7]). We found a positive relationship between clinical judgment skills and safe medication practices (r = 0.39, t27 = 2.94, P = .018). The clinical reasoning process of Interpreting was a significant indicator of best practices (b = 1.4, t28 = 2.81, P = .010).

CONCLUSION

Our findings suggest that students struggle to connect theory to practice, emphasizing the need to plan experiential learning opportunities for students to develop clinical reasoning, particularly in Interpreting, and judgment skills to prevent medication errors upon entry to practice.

Three learning modalities' impact on clinical judgment and perceptions in newly graduated registered nurses: A quasi-experimental study

Newly graduated registered nurses face numerous challenges stemming from high patient workload, complicated interpersonal relationships, and a lack of nursing competence, which can lead to transitional shocks. Clinical judgment and confidence are well-known keys to successful role transitions for these nurses. Simulation training is proposed as a new modality for enhancing comprehensive clinical competence of nurses, but current evidence on the impact of different simulations on nurses' clinical judgment and confidence are still limited or inconsistent. This study compared the impact of three types of learning modalities on newly graduated registered nurses' clinical judgment, perceptions of self-confidence, and evaluations of the design features of the learning modalities. A quasi-experimental design was used. Fifty-nine participants were randomly assigned to three groups: (1) high-fidelity simulation, (2) virtual simulation, and (3) case study. Scales were used after the simulation. The virtual simulation group showed a higher level of clinical judgment. The high-fidelity simulation group felt more confident than the virtual simulation and case study groups. Both the high-fidelity simulation group and virtual simulation group reported higher scores in the domain of fidelity.

Efficacy of a Simulation Program to Improve Clinical Judgment and Clinical Competence Among Graduate Nurses

AIM

This two-group feasibility study tested the efficacy of a four-scenario simulation program to improve clinical judgment and clinical competence among graduate nurses.

BACKGROUND

Clinical judgment and clinical competence are underdeveloped among new-to-practice nurses.

METHOD

Clinical judgment was compared between the intervention group (n = 17) and a control group (n = 26) in the practice setting at two time points.

RESULTS

The simulation program had a large effect on the intervention group's clinical judgment (η2 = .143) and clinical competence (η2 = .153). There were no statistically significant differences for each outcome at baseline as compared to the final scenario for the intervention group. There was no statistical significance between the intervention and control groups in clinical judgment in the practice setting at each measurement time.

CONCLUSION

Replication of the study with a randomized controlled trial and large sample size is warranted.

Aspectos positivos e negativos da simulação clínica no ensino de enfermagem

Resumo Objetivo descrever os aspectos positivos e negativos da simulação clínica no ensino de enfermagem na perspectiva dos graduandos. Método estudo transversal descritivo de abordagem qualitativa, desenvolvido em uma universidade federal do Rio de Janeiro. A coleta de dados ocorreu após a realização da simulação clínica acerca do exame físico do paciente, onde se sucedeu uma discussão com os alunos acerca de suas percepções. O conteúdo textual decorrente das entrevistas foi submetido à análise lexicográfica, utilizando-se o software Interface de R pour Analyses Multidimensionnelles de Textes et de Questionneires (IRAMUTEQ). Resultados os aspectos positivos da simulação clínica no ensino de enfermagem versam sobre a importância da simulação na preparação dos alunos para a prática clínica, favorecendo a correlação entre teoria, prática e o desenvolvimento do raciocínio crítico. Dentre os negativos, destacaram-se o nervosismo e a dificuldade em realizar as ações com os demais colegas observando. Conclusão e Implicações para a prática a simulação demonstrou ser uma ferramenta significativa e viável para o ensino em enfermagem. Recomenda-se que esta estratégia seja adotada a fim de contribuir na formação de profissionais reflexivos e aptos para prestar os cuidados sem erros, contribuindo para a segurança do paciente.

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.