Current Practices for Teaching Clinical Judgment: Results From a National Survey

Promoting Safe Practice in New Graduate Nurses: The Key Role of Support

This article reports research that examined how registered nurses in practice develop clinical judgment in new graduate nurses (NGNs) and how NGNs respond. Teaching themes were setting the tone for learning, use of cognitive-focused teaching-learning strategies, including mentoring thinking, debriefing and reflection, and using real-life scenarios. NGN responses were learning focused, emotional, or resistant. Recommendations to support development of clinical thinking are made.

Assessing Clinical Judgment and AACN Domains in Self-Reflection of Video Recorded High-Fidelity Simulation Scenarios

BACKGROUND

Clinical judgment is the hallmark of safe patient care. Nurse educators continue to explore best practices to assist prelicensure nursing students in developing clinical judgment.

PURPOSE

The 3-part purpose of this study was to identify what students learned about themselves related to clinical judgment after viewing their video-recorded high-fidelity simulation scenarios, to assess if video recording is an effective post-debriefing teaching strategy, and to evaluate if the 2021 American Association of Colleges of Nursing (AACN) Domains can be assessed longitudinally.

METHODS

Qualitative interpretive description study of 37 prelicensure nursing students.

RESULTS

Ten codes were derived from 314 excerpts: communication, body language, confidence in self, putting data together, collaboration, leadership, safety, skillfulness, areas of improvement, and growth.

CONCLUSIONS

Longitudinal data showcased the development of clinical judgment, effectiveness of self-evaluation of video recorded simulations as a teaching strategy, and assessment of 5 AACN Domains.

Investigating clinical decision-making in bleeding complications among nursing students: A longitudinal mixed-methods study

AIM

To describe undergraduate nursing students' clinical decision-making in post-procedural bleeding scenarios and explore the changes from the first to the final year of their program.

BACKGROUND

Bleeding is a common complication following invasive procedures and its effective management requires nurses to develop strong clinical decision-making competencies. Although nursing education programs typically address bleeding complications, there is a gap in understanding how nursing students make clinical decisions regarding these scenarios. Additionally, little is known about how their approach to bleeding management evolves over the course of their education.

DESIGN

Longitudinal mixed-methods study based on the Recognition-Primed Decision Model.

METHODS

A total of 59 undergraduate students recorded their responses to two clinical decision-making vignettes depicting patients with signs of bleeding post-hip surgery (first year) and cardiac catheterization (final year). Their responses were analyzed using content analysis. The resulting categories capture the cues students noticed, the goals they aimed to achieve, the actions they proposed and their expectations for how the bleeding situations might unfold. Code frequencies showing the most variation between the first and final years were analyzed to explore changes in students' clinical decision-making.

RESULTS

Nearly all students focused on two primary categories: 'Bleeding' and 'Instability and Shock.' Fewer students addressed six secondary categories: 'Stress and Concern,' 'Pain,' 'Lifestyle and Social History,' 'Wound Infection,' 'Arrhythmia,' and 'Generalities in Surgery.' Students often concentrated on actions to manage bleeding without further assessing its causes. Changes from the first to the final year included a more focused assessment of instability and shifts in preferred actions.

CONCLUSIONS

This study reveals that nursing students often prioritize immediate actions to stop bleeding while sometimes overlooking the assessment of underlying causes or broader care goals. It suggests that concept-based learning and reflection on long-term outcomes could improve clinical decision-making in post-procedural care.

Bridging the experience-complexity gap with longitudinal clinical placements

BACKGROUND

Clinical learning is a critical element to prepare nursing students for the profession. There is limited evidence on the experience-complexity gap among novice nursing students entering the workforce.

PURPOSE

This study aimed to implement a novel longitudinal clinical experience program and examined readiness for practice for undergraduate nursing students.

METHODS

We used a prospective cohort design using the Casey-Fink Readiness for Practice survey.

FINDINGS

There have been 2,004 clinical placements filled since the start of the program. Repeated exposure at one organization provided consistency and continuity while allowing students to develop relationships with patients and staff in a variety of settings. The medical-surgical two clinical experience was a pivotal course that influenced students' perception to enter the nursing workforce.

DISCUSSION

Clinical and academic partners must collaborate to provide the necessary competencies required to enter the workforce. Longitudinal clinical programs may improve nursing students readiness for practice.

CONCLUSION

The continous and immersive nature of the longitudinal clinical experience program facilitated the development of critical thinking skills and clinical competence, suggesting that longitudinal clinical placements can bridge the experience-complexity gap in nursing education.

Observed Use of Clinical Judgment Among New Graduate Nurses

BACKGROUND

Despite the efforts of academic nursing educators to prepare students to make sound clinical judgments, the literature suggests new graduate nurse (NGN) competence with this critical skill continues to decline. This study sought to identify how practicing nurses describe their observations of the use and outcomes of clinical judgment by NGNs in nursing practice.

METHOD

A multisite, cross-sectional survey using multiple-choice, Likert scale, and open response items to identify participants' observations of NGN clinical judgment was sent with snowball sampling and resulted in a sample of 314 participants from 19 U.S. states.

RESULTS

Practice partners identified a wide discrepancy between how they expect NGNs to use clinical judgment and what they actually see NGNs do, with resultant negative effects on patients and NGNs.

CONCLUSION

These results provide a beginning understanding of NGNs' specific challenges with clinical judgment. Efforts to improve clinical judgment across nursing education and practice are needed. [J Contin Educ Nurs. 2024;55(8):399-406.].

Evaluation of the Maryland Next Gen Test Bank Project: Implications and Recommendations

AIM

The aim of this study was to evaluate the development and impact of a project to create a statewide test bank of Next Generation NCLEX®-style items.

BACKROUND

Using a train-the-trainer model, champions created an open access resource of Next Generation NCLEX-style items to use to teach clinical judgment and then trained peers on item writing and test bank use.

METHOD

Stufflebeam's CIPP (context, inputs, process, and products) model provided the framework for the evaluation. Data were synthesized from multiple sources including participation rates, item utilization, and survey data.

RESULTS

Twenty faculty from 13 schools were trained as champions and submitted 54 case studies, 33 bowties, and 21 trend items to the test bank. Items were used over 60,000 times in the first year.

CONCLUSION

The statewide test bank met a need for more teaching resources. The train-the-trainer model was an effective strategy for helping faculty learn to prepare for Next Generation NCLEX.

Effectiveness of a Simulation-Based Education Program to Improve Novice Nurses' Clinical Judgment Skills

INTRODUCTION

We assessed the effectiveness of a simulation-based education program to improve novice nurses' clinical judgment skills.

METHODS

A simulation education program was implemented for 21 novice nurses. Surveys were conducted on program satisfaction, learning, and clinical judgment skills before, immediately after, and two months after the program.

RESULTS

Novice nurses were highly satisfied with the simulation education program. The following nine categories were identified as learnings: provide psychological care for patients, conduct sufficient observation, conduct assessment and make judgment based on observational findings, consult and report appropriately to senior nurses, take response action calmly, collect necessary information, acquire knowledge, predict patients' conditions, and make environmental arrangements. The subscale score for theoretical and practical reasoning was significantly higher immediately after and two months after the program than before it. In addition, the subscale for grasping the condition by observation was significantly higher two months after the program than before and immediately after it.

CONCLUSION

The novice nurses learned to sufficiently observe, obtain necessary information, and prospectively assess patients' conditions by taking part in the simulation education program. The subscale score for grasping the condition by observation was significantly higher two months after the program than before and immediately after it. After the simulation program, novice nurses were likely actively practicing nursing; therefore, this program may not be directly responsible for the improvement of these new nurses' clinical judgment. Nevertheless, we found that the completion of the simulation program was correlated with enhanced clinical judgment.

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.

Aligning Simulation-Based Education With Didactic Learning in Prelicensure Baccalaureate Nursing Education

BACKGROUND

Research has shown there is a gap between academia and practice. Nursing stakeholders support the use of the clinical judgment model in developing competency for practice.

PURPOSE

This study analyzed the effectiveness of simulation-based education on the development of clinical judgment and explored new graduate nurses' perceptions of their preparation for practice.

METHODS

A longitudinal, explanatory, mixed-methods design with survey points at onset and end of the intervention and interviews 6 months postgraduation.

RESULTS

The Simulation Effectiveness Tool-Modified (SET-M) was utilized for the pre- and posttest surveys. Two-tailed Mann-Whitney 2-sample rank sum tests were conducted and analyzed for all items on the SET-M. Significant differences were seen in pre- and posttest responses for 12 of the 19 SET-M survey items.

CONCLUSION

The findings of this study support the deliberate alignment of didactic and practical teaching strategies to strengthen practice performance and bridge the gap.

Evaluating the Importance of Clinical Judgment in Entry-Level Nursing

BACKGROUND

This study investigated the extent to which clinical judgment is important in entry-level nursing practice.

METHOD

A task analysis linkage study methodology based on a large-scale, comprehensive practice analysis was used for the study. The practice analysis validated more than 200 entry-level nursing tasks, and the linkage study sought to evaluate the importance of clinical judgment overall and for each specific task expectation.

RESULTS

The results provide confirmatory evidence of the importance of clinical judgment. In addition, the work provides a comprehensive list of entry-level tasks and their associated clinical judgment importance.

CONCLUSION

Clinical judgment is a vital skill at entry into the profession and is expected to grow over time. This study offers insights on the extent to which clinical judgment is a necessary skill and provides direct evidence of its importance for specific entry-level tasks. [J Nurs Educ. 2024;63(3):156-162.].

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.

An integrative review of teaching strategies to support clinical judgment development in clinical education for nurses

OBJECTIVES

Historically, emphasis on task-completion and lack of intentional approaches that develop students' thinking skills have dominated clinical education. One contributing factor may be the limited literature about teaching to develop clinical reasoning and clinical judgment in the clinical environment. This integrative review accessed available literature to answer the question, What strategies are used to develop clinical judgment in the clinical education environment?

DESIGN

The Whittemore and Knafl approach framed the integrative review. The framework includes the following steps 1) problem identification, 2) literature search, 3) data evaluation, 4) data analysis, and 5) presentation.

DATASOURCES

The data bases CINAHL Plus with Full Text, OVID, and ProQuest were searched through the period of January 2000 through July of 2022.

REVIEW METHODS

The PRISMA protocol informed review and screening of the literature. Authors assessed articles for eligibility via first screening by abstract review, followed by review of the full text. Both authors reviewed the articles, assessing qualification for inclusion and evaluating the content. Data from eligible articles were analyzed and synthesized to answer the research question.

RESULTS

Of the initial 427 articles, a total of 20 articles met inclusion criteria for final analysis. Five general themes emerged for clinical judgment during clinical education. The findings identified the teaching strategies nurse educators use. Many of the teaching methods include deliberateness and intentionality in planning and implementing the strategies. In addition to evaluating clinical judgment, nurse educators guided and mentored student thinking. Finally, this review identified reported outcomes and results of the teaching strategies and methods.

CONCLUSIONS

A limited number of articles describing teaching for clinical judgment in clinical environment were found. The articles analyzed found that nurse educators used a variety of teaching strategies for the purpose of developing students' clinical judgment. More research is needed to guide best-practices in clinical education. We must move the science forward to transform and leverage clinical education more deliberately to teach thinking in practice and decision-making about patient care.

Early Prelicensure Nursing Students' Perceptions of Case Studies Through the Lens of the Clinical Judgment Measurement Model

BACKGROUND

Research indicates new nursing graduates struggle with clinical reasoning, despite some related skill development throughout their education. The question remains, "Could an earlier focus on clinical reasoning in nursing programs enhance nursing students' clinical reasoning?"

PURPOSE

This pilot study investigated how first-semester nursing students perceive the use of case studies in clinical reasoning skill development and the perceived benefits of case studies related to the NCSBN Clinical Judgment Measurement Model (NCJMM).

METHODS

Case studies and written reflections were introduced to a convenience sample (n = 45) of first-semester nursing students. Qualitative analysis was conducted on written reflections.

RESULTS

Students found case studies enhanced their knowledge and prepared them for clinical practice as a nurse.

CONCLUSIONS

Findings suggest early introduction of case studies is a meaningful teaching strategy to develop clinical reasoning aligned with the NCJMM.

Barriers and Facilitators Experienced by Undergraduate Nursing Faculty Teaching Clinical Judgment: A Qualitative Study

Background

Clinical judgment is declining in new graduate nurses, which affects patient safety and is therefore tested on the Next Generation NCLEX. There is limited research describing barriers and facilitators impacting nursing faculty's experiences teaching clinical judgment.

Aims

The purpose of this study was to explore barriers and facilitators affecting undergraduate nursing faculty's clinical judgment teaching methods.

Methods

Sixteen qualitative interviews were conducted with full-time nursing faculty at seven universities in the Northeast and Southeast regions of the United States.

Results

The findings revealed program, student, and faculty factors affecting clinical judgment teaching methods. Subthemes included time, class size, students' class preparation, critical thinking, task orientation, professional development, and faculty resistance.

Conclusion

Minimizing barriers and strengthening facilitators based on participants' practices and previous research can support more effective clinical judgment pedagogy, which has the potential to achieve Next Generation NCLEX success and potentially increase patient safety.

Brain Science Learning Guides: An Innovative Strategy for Cultivating Effective Study Skills

BACKGROUND

Students often struggle with how to synthesize course content during independent learning outside of class.

PROBLEM

Study strategies may be entrenched in ineffective methods that reinforce misperceptions of learning and undermine the development of metacognitive thinking.

APPROACH

To promote the development of effective study skills, a scaffolded approach was developed to facilitate students actively engaging with course content outside of class time, based on best practices of brain science-based learning.

OUTCOMES

Using evidence in the brain science of teaching and learning, Learning Guides were developed to shift the focus of study outside of class time from the "what" to the "how." Preliminary feedback from students in multiple core nursing courses suggests that these guides are an effective tool for student learning.

CONCLUSION

This brain science-based approach to learning can provide a road map for students to build the essential skills for effective study habits that can lead to durable learning.

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.

Impact of a Virtual Patient Simulation on Nursing Students' Attitudes of Transgender Care

BACKGROUND

Transgender individuals experience considerable prejudice and bias, creating barriers to health care.

PURPOSE

The purpose of this study was to determine the effect of a virtual patient simulation scenario of caring for a transgender adult on nursing students' attitudes and beliefs about transgender people.

METHODS

A validated 29-item instrument developed to assess an individual's view of transgender identity was administered in a pre-/posttest nonequivalent-groups design to junior- and senior-level nursing students.

RESULTS

Statistically significant differences were found between the control and treatment groups for the subscale human value.

CONCLUSIONS

Findings support experiential learning in nursing as an effective tool in teaching cultural competence and sensitivity when caring for transgender patients. Attitudes and beliefs of senior nursing students and junior nursing students toward transgender individuals differed, with senior students being more receptive.