Learning to think like a nurse: the development of clinical judgment in nursing students

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.

The Factors Influencing Nurses' Clinical Decision-Making in Emergency Department

In an emergency, making the correct decision is vital. It is a necessary element of professional nursing care, and the ability of nurses to make successful clinical decisions is the most critical element influencing care quality. The purpose of this study was to assess the factors influencing nurses' clinical decision-making in the emergency department of Palestinan hospitals. A cross-sectional study was targeted at all nurses working in emergency departments at the Palestinian hospitals. The study was completed with 227 nurses, and collecting data was performed with the Clinical Decision Making in Nursing Scale. Results of the study revealed that the average score for the total clinical decision-making score was 3.3 (SD = 0.23). The subscales of clinical decision making were "search for alternatives or options," "canvassing of objectives and values," "evaluation and reevaluation of consequences," and "search for information and unbiased assimilation of new information." Furthermore, multiple linear regression analysis revealed that degree and work hours accounted for 11.7% of the variance in clinical decision-making. The study confirmed the average score for clinical decision-making was slightly higher than the average score. Also, it approved that nursing degree and work hours were predictors of clinical decision-making among nurses in emergency departments.

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

BACKGROUND

Safe patient care is closely linked to clinical judgment. Concerns about inadequate practice readiness and the impending inclusion of clinical judgment items on the NextGen NCLEX have resulted in increasing interest and publications about teaching clinical judgment. However, little is known about actual current practices for teaching this skill.

PURPOSE

This research describes findings about current strategies to teach clinical judgment used in US prelicensure nursing programs.

METHODS

Cross-sectional methodology was used to survey program deans and directors across the United States.

RESULTS

Programs are using multiple strategies to teach clinical judgment. The most common strategies used include case studies and simulation. Participants believed strategies have a positive impact on student thinking, practice readiness, and program outcomes. They described insights into implementation of teaching for clinical judgment.

CONCLUSION

The results of this research provide foundational data to inform current teaching practices and further research for this essential skill.

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.].

Nursing Students' Cue Recognition in Educational Simulation: A Scoping Review

BACKGROUND

New nurses often struggle with recognizing cues and applying clinical judgment. Nurse educators develop educational simulation scenarios to support students in developing clinical judgment, which includes the foundational step of recognizing cues.

PURPOSE

A scoping review on undergraduate nursing students' cue recognition during simulation was conducted to systematically map the existing research and identify knowledge gaps.

METHODS

From initial identification of 228 studies published between 2010 and 2020, a total of 17 quantitative or qualitative studies were independently appraised using the Joanna Briggs Institute scoping review process and PRISMA-ScR reporting guidelines.

RESULTS

Cues were missed with varying levels of frequency. Participants frequently failed to recognize respiratory rates and physical assessment changes as salient cues to patient deterioration. Verbal cues from simulated patients were often missed or resulted in distancing behaviors.

CONCLUSION

Research is needed to determine the most effective methods for helping learners develop skills in cue recognition and analysis.

Nursing students' development of using physical assessment in clinical rotation-a stimulated recall study

Background

The overall aim of this study was to explore third-year bachelor nursing students’ stimulated recall reflections on their physical assessment competence development. The choice of learning strategies in nursing education seems to have great impact on nursing students’ use of physical assessment skills while in clinical rotation. There is a need to explore nursing students’ learning processes related to the use of physical assessments.

Methods

Explorative qualitative design using a triangulation of data collection methods. Nine final-year nursing students’ physical assessment performances during patient encounters were audio-taped and observed. Shortly after, an individual stimulated recall interview based on the audio-recorded patient encounter and observation notes was conducted. A two-fold analysis was conducted: 1) analysis of students’ performed assessments, and 2) phenomenological hermeneutical analysis of the stimulated recall interviews.

Results

Nursing students assessments shifted from a checklist approach to a symptom-based, more holistic and person-centred approach, emphasizing conversation as part of their assessments. The nursing students also reported that a safe and stimulating learning environment was a prominent feature for their continuing development. Learning from skilled role models with expectations to them using physical assessment skills facilitated their continuing skills appliance, interprofessional communication and reflective practice.

Conclusions

This study contribute with a novel, comprehensive and in-depth description of what influenced nursing students’ learning processes experiences of using physical assessment skills during clinical rotation. The results reveal the need for targeted course designs by implementing scaffolded learning activities in practical and theoretical courses aimed at strengthening students’ learning of physical assessment skills—building upon and emphasizing their prior knowledge and competence, which may lead to more confident registered nurses and promote patient safety in different health care contexts. We propose using stimulated recall systematically as a novel reflective learning activity in nursing education to foster clinical reasoning and metacognition skills and achieve deep learning.

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.

Advancing Nurse Scope of Practice in the Republic of Moldova Using Simulation

BACKGROUND

Nurse identity in the Republic of Moldova is undergoing change to achieve recognition as a profession. This article describes a faculty development program designed to help articulate the professional nurse role and scope of practice through enhanced teaching pedagogies used in basic nursing education.

METHOD

Experiential learning strategies such as high-fidelity simulation, unfolding geriatric case study, role-play, task trainers, moulage, and teach-back were used to demonstrate the nursing process and scope of practice.

RESULTS

Fifteen faculty from five technical colleges of nursing participated in the Geriatric Nursing Institute (GNI). Debriefings yielded positive responses on using experiential learning strategies to augment didactic methods to facilitate student competencies, nurse identity, and scope of practice.

CONCLUSION

The GNI contributed to the professional development of faculty with potential impact on nursing students to achieve enhanced preparedness in global nurse competencies. Although the pedagogical innovations were welcomed, future initiatives building on the GNI are needed. [J Nurs Educ. 2021;60(7):377-385.].

An integrative review of simulation, senior practicum and readiness for practice

Readiness for practice (RFP) is essential as new nurses will practice in a nursing shortage climate, with high acuity patients and complex technology. Nurse educators are challenged to foster readiness for practice.

AIM

The aim of this integrative review was to explore the impact of simulation and senior practicum on graduating senior nursing students' readiness for practice.

BACKGROUND

Readiness for practice has been a point of concern for healthcare for quite some time. This has led to a need for better understanding for what RFP means including their perceptions of various stakeholders. Further, it is important to address what teaching and learning strategies can be implemented to assist in ensuring the graduating senior nursing student is ready for practice on graduation and for their first professional practice. Readiness for practice is defined as the ability to safely and competently care for patients by synthesizing theory, skills, attitudes and values in applying clinical reasoning in practice settings.

METHOD

An integrative review identified 48 published papers on simulation and senior practicum that met the inclusion criteria.

RESULTS

Themes identified from the senior practicum/preceptor literature included clinical reasoning, skills, barriers to the senior practicum and transition. Themes identified regarding simulation as a strategy included preparation, competence development, clinical reasoning and the number of human patient simulators used.

CONCLUSION

Although the evidence is not conclusive, simulation and senior practicums have the promise of preparing graduating nursing students for their first professional practice. However, nurse educators must ensure simulations are well-organized with clear objectives and that preceptors are supported in teaching and assessing students.

Nursing Students' and Preceptors' Experiences with Using an Assessment Tool for Feedback and Reflection in Supervision of Clinical Skills: A Qualitative Pilot Study

Background

There is a need to improve students' learning in clinical practice. Undergraduate students need guidance when it comes to transferring knowledge from the classroom to clinical practice in community health services. Competence Development of Practical Procedures (COPPs), a simulation assessment tool, was used to explore students' and preceptors' experiences with feedback and reflection during the supervision of clinical skills in real practice.

Method

This was a pilot study with a qualitative exploratory and descriptive research design. Four students in their first year of a bachelor's programme in nursing and four preceptors participated. Data were collected from eight clinical skills performance assessments, audio recordings of supervision, and open-ended questionnaires. Data were systematized, categorized, and analysed using qualitative content analysis. Findings. Participants' experiences were divided into five categories: “learning environment, an atmosphere of respect, acceptance, and encouragement,” “students' reflections on their own personal learning,” “students' reflections on various care situations,” and “students' and preceptors' assessment and feedback.” Participants found COPPs easy to use and providing structure for assessment, feedback, and reflection during supervision. Concepts related to learning clinical skills became visible for both students and preceptors and helped students assess their performance of clinical skills. Through verbalization and reflection in supervision, participants established a consensus around what students knew and what they needed to learn.

Conclusions

The students and preceptors experienced the tool as a supportive structure to enhance feedback and reflection for the learning of clinical skills in municipal healthcare services. COPPs filled a gap in practice by providing a language for students and preceptors to articulate their knowledge and increasing students' awareness of what constitutes a good performance. The tool supported the coherence of concepts, enhanced clinical reasoning, and promoted deeper thinking and reflection, and the students gained insight into their own needs related to learning clinical skills.

Nurse Faculty Experiences Teaching Chronic Illness Self-Management Concepts: An Exploratory Study

AIM

The aim of the study was to explore how nurse faculty prepare students to teach chronic disease self-management.

BACKGROUND

Self-management addresses patient activities in response to a change in baseline health. Evidence suggests nurses may not be educated on how to engage patients in chronic disease self-management.

METHOD

This qualitative study used semistructured interviews to explore experiences of 13 nurse faculty across three universities in preparing nursing students to address self-management concepts for adults living with chronic disease.

RESULTS

Three themes emerged from 104 identified significant statements: conceptualizing and valuing chronic disease self-management in nursing education, making chronic disease self-management fit, and sharing the impact of health care reform on chronic disease care.

CONCLUSION

Self-management is regarded as highly complex and evolving. As such, nursing education curricula must also evolve to emphasize successful approaches to preventing chronic disease and incorporating chronic disease self-management and behavior modification in the curriculum.

The role of manikins in nursing students' learning: A systematic review and thematic metasynthesis

OBJECTIVES

To summarise and synthesise findings from qualitative primary research studies of nursing students' experiences from educational activities using manikins to gain a deeper understanding of the role these manikins play in the students' learning.

DESIGN AND DATA SOURCES

A systematic review and thematic metasynthesis were conducted. Cinahl+, Ovid Medline, ERIC and Embase were searched systematically.

REVIEW METHODS

Sandelowski and Barroso's framework guided the review process. A comprehensive search to identify qualitative studies of nursing students' experiences from learning with manikins was performed in January 2019 and updated in April 2020. Study selection was guided by six screening questions derived from these inclusion criteria: qualitative primary studies, published from 2008, in English or Scandinavian, presenting findings of undergraduate nursing students' experiences with manikins at all fidelity levels. Thomas and Harden's method for thematic synthesis was followed.

RESULTS

Twenty-eight articles of twenty-seven studies were included. We identified three synthesised analytic themes: Seeing the manikin as a doll or a patient, Experiencing yourself as a nurse caring for a patient, and Being a team member.

CONCLUSIONS

When it is perceived as a patient, a manikin can give students a realistic experience of what it means to behave like nurses. Consequently, this realism lets students practice and acquire relational, communicative, and collaborative nursing skills. Using a manikin can facilitate the development of students' professional identity.

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.].

Reflection on actions: Identifying facilitators of and barriers to using physical assessment in clinical practice

Current research suggests that nursing students do not apply all sets of physical assessment skills (PAS) learned in their nursing education. The aim of this study was to evaluate third-year nursing students' process of clinical judgment using PAS in clinical rotation. Specific focus was on how the process of clinical judgment affected when the nursing students performed physical assessment, and which types of knowledge were implied in their practice. Ten nursing students performed PAS independently while in clinical rotation; these performances were audiotaped and observed. Shortly after, individual semi-structured stimulated recall interviews (SRI) took place. Regardless of the nursing students' stated level of PAS utilization, self-efficacy or scientific knowledge, clinical judgment was primarily based on contextual factors and personal prerequisites. This study contributes to in-depth knowledge about how nursing students perform physical assessment, how they describe their clinical judgment process and their strategies towards systematically and confidently using PAS. We conclude the paper with pedagogical strategies and learning activities that can facilitate reflection-in-action and reflection-on-action.

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.

Evaluation of Clinical Judgment in Prelicensure Nursing Students

Clinical judgment is an essential end-of-program outcome for prelicensure nursing students. Evaluating progression of clinical judgment when students participate in simulated patient experiences is essential in ensuring that end-of-program and course outcomes are achieved. The purpose of this study was to identify if progression in clinical judgment is evident after students participate in 4 simulated patient experiences as measured by the Lasater Clinical Judgment Rubric.

Factors Influencing Nursing Students' Clinical Judgment: A Qualitative Directed Content Analysis in an Iranian Context

INTRODUCTION

Clinical judgment is necessary for clinical decision making and enhancing it in nursing students improves health care quality. Since clinical judgment is an interactive phenomenon and dependent on context and culture, it can be affected by many different factors.

AIM

To understand the experiences of Iranian nursing students and teachers about the factors influencing nursing students' clinical judgment.

MATERIALS AND METHODS

A qualitative study was conducted using a directed content analysis approach. In this study, purposive sampling and semi-structured interviews were applied with seven nursing students, six faculty member teachers and four clinical instructors from Guilan University of Medical Sciences, Gilan, Iran.

RESULTS

The factors influencing nursing students' clinical judgment consisted of five main categories including thoughtful behaviour, professional ethics, use of evidence based care, the context of learning environment and individual and professional features of clinical teachers.

CONCLUSION

Relying on the results of this research, teachers can create an appropriate educational condition and a safe psychological atmosphere, use instructional strategies strengthening deep thought processes, applying professional ethics and scientific evidence and principles to establish clinical judgment in nursing students.

Impact of prebriefing on competency performance, clinical judgment and experience in simulation: An experimental study

BACKGROUND

Prebriefing is the introductory phase of the simulation process, however, little nursing education research is available on this aspect of simulation. Reflection theory and concept mapping informed a model-based structured prebriefing activity to prepare students for meaningful simulation learning.

OBJECTIVES

The aim of this study was to examine the intervention of structured prebriefing for its effect on nursing students' competency performance, clinical judgment and their perceived prebriefing experience.

DESIGN

An experimental group-randomized design was used in this study; the intervention group who received structured prebriefing was compared to the control group.

SETTING

The study was conducted at a university school of nursing in Canada.

PARTICIPANTS

Baccalaureate nursing students (N=76) enrolled in a fourth-year medical-surgical course participated in this study.

METHOD

Competency performance, clinical judgment, and the perception of the prebriefing experience of those participants receiving structured prebriefing and those receiving traditional prebriefing activities, were compared. The relationship between simulation performance and students' self-rated prebriefing experience was also examined. Scores from the Creighton Competency Evaluation Instrument and the Prebriefing Experience Scale were analyzed using parametric and non-parametric statistics.

RESULTS

A statistically significant difference was demonstrated between groups for competency performance (p<0.001), clinical judgment (p<0.001) and prebriefing experience (p<0.001). No relationship was found between perception of prebriefing experience and students' simulation performance.

CONCLUSION

Theory-based, structured prebriefing can impact nursing student competency performance, clinical judgment and perceptions of prebriefing, and may enhance meaningful simulation learning.

Accuracy of intuition in clinical decision-making among novice clinicians

AIMS

To assess the reliance on intuitive and analytical approaches during clinical decision-making among novice clinicians and whether that reliance is associated with accurate decision-making.

BACKGROUND

Nurse educators and managers tend to emphasize analysis over intuition during clinical decision-making though nurses typically report some reliance on intuition in their practice. We hypothesized that under certain conditions, reliance on intuition would support accurate decision-making, even among novices.

DESIGN

This study utilized an experimental design with clinical complication (familiar vs. novel) and decision phase (cue acquisition, diagnosis and action) as within-subjects' factors, and simulation role (observer, family, auxiliary nurse and primary nurse) as between-subjects' factor.

METHODS

We examined clinical decision-making accuracy among final semester pre-licensure nursing students in a simulation experience. Students recorded their reasoning about emerging clinical complications with their patient during two distinct points in the simulation; one point involved a familiar complication and the other a relatively novel complication. All data were collected during Spring 2015.

RESULTS

Although most participants relied more heavily on analysis than on intuition, use of intuition during the familiar complication was associated with more accurate decision-making, particularly in guiding attention to relevant cues. With the novel complication, use of intuition appeared to hamper decision-making, particularly for those in an observer role.

CONCLUSION

Novice clinicians should be supported by educators and nurse managers to note when their intuitions are likely to be valid. Our findings emphasize the integrated nature of intuition and analysis in clinical decision-making.

Cooperative Clinical Conferences: Nursing Student Pediatric Clinical Innovation

BACKGROUND

A gap exists between nursing student classrooms (i.e., clinical training) and newly graduated RNs' real-world nursing experiences. The Cooperative Clinical Conference (CCC) was piloted for prelicensure nursing clinical groups as a vehicle to allow students to reflect on their learning and physiology and disease, as it relates to the pediatric patient in the context of the entire plan of care for pediatric patients.

METHOD

Participating nursing student clinical groups were allotted 15 to 20 minutes to give group case presentations of de-identified patient scenarios, representative of the patient population on the assigned clinical unit.

RESULTS

The CCC as a learning opportunity in the clinical area was rated highly on evaluations by faculty and student participants in terms of their achievement of both learning objectives and satisfaction.

CONCLUSION

The CCC represented a feasible and acceptable method of enhanced learning and professional development with and for undergraduate nursing students in the pediatric clinical environment. [J Nurs Educ. 2016; 55(7):416-419.].