New graduate registered nurses need clinical judgment skills to ensure patient safety and improve patient outcomes in complex healthcare environments. The National Council of State Boards of Nursing (NCSBN) found that the current National Council Licensure Exam (NCLEX-RN®) does not measure all levels of clinical judgment (Dickison et al., 2019). As a result of their findings, NCSBN is planning a significant revision of NCLEX-RN®, including evaluating nursing graduates' clinical judgment. New registered nurses face increasing challenges, including high nurse/patient ratios and an increase in chronic illnesses (Woda et al., 2019). Nursing students need to develop clinical judgment skills (Ashcraft et al., 2013; Martin et al., 2020; Yang et al., 2019) and it is essential that opportunities to do so are provided in undergraduate nursing programs (Dickison et al., 2019).
Simulation offers nursing students opportunities to use clinical reasoning and clinical judgment to care for patients in a safe environment (Nursing Association for Clinical Simulation & Learning, 2016). It also allows nursing students to engage in activities that do not occur frequently in traditional clinical settings. Simulation allows nurse educators to prepare future registered nurses to use clinical judgment skills to recognize cues, hypothesize, and prioritize care, and to act quickly and appropriately to prevent negative patient outcomes. Using simulation with standardized patients and high-fidelity mannequins is an effective strategy that can be integrated throughout the curricula to build clinical judgment skills (Ashley & Stamp, 2014; Bussard, 2018; Martin et al., 2020; Salameh et al., 2021; Yang et al., 2019).
We designed a simulation that incorporated the use of an unfolding case study that required nursing students to make clinical judgments over time in three distinct settings – a primary care office, an acute care hospital, and a home healthcare setting. Although literature is abundant on simulation and various healthcare settings, there is little research on simulation occurring on a continuum in three healthcare settings. Home healthcare is expanding as care moves increasingly from acute care settings to care in the community. Home healthcare experiences are important for nursing students because most undergraduate clinical learning occurs within acute care settings (Watkins & Neubrander, 2020).
The unfolding case study was based on a patient with type 2 diabetes. Diabetes is a serious chronic illness. According to the Centers for Disease Control and Prevention (2018), 32.4 million Americans have diabetes, and another 88 million Americans have prediabetes. Patient education is essential to prevent serious long-term effects of diabetes (Woda et al., 2019). In addition to patient education, nursing interventions for patients with diabetes include glucose monitoring, nutrition, insulin administration, foot care, and recognizing and treating clinical manifestations of hypoglycemia and hyperglycemia. This simulation allowed student nurses to use clinical judgment to monitor a patient for complications of diabetes and provide diabetes education. The purpose of this study was to explore the effect of participating in an unfolding case study using high-fidelity simulation across three practice settings (primary care, acute care, and home healthcare) on nursing students' self-report of clinical judgment skills.
Tanner's Integrative Model of Clinical Judgment (IMCJ) guided the development of this simulation scenario. This model maintains that clinical judgment includes four phases: 1.) noticing initial assessment findings (context, background, interpreting by analyzing patterns; 2.) prioritizing data; 3.) responding in action; and 4.) reflecting on outcomes (Tanner, 2006). The IMCJ emphasizes engagement with patients and development of concern and caring for the patient's well-being and allows clinical experiences, knowledge, and relationship with patients to influence clinical judgment (Tanner, 2006). The IMCJ model was used by NCSBN to revise the NCLEX-RN® and to encourage nurse educators to give students opportunities to develop and practice clinical judgment skills (NCSBN, 2019). Caring for the same patient in three settings allowed the students to build a relationship with the patient and recognize patterns of subjective and objective data (cues), interpret the data in all three settings, prioritize hypotheses, and respond and participate in reflection during debriefing after each scenario. Tanner's IMCJ model is well published in nursing education and implemented widely as it gives nursing students a beginning understanding of how to think like a nurse in an environment that is dynamic (Jeong & Choi, 2017).
A mixed-method, posttest design was implemented for this study. The participants were 91 junior-level nursing students in a baccalaureate nursing program who were enrolled in Adult Health I Medical-Surgical course that concentrates on chronic illnesses. The simulation took place in the university's interprofessional simulation center and participation was required as part of the course. Students completed the standard coursework that included lecture, presimulation preparation, the simulation, and debriefing. Following the educational intervention, participants completed the Lasater Clinical Judgment Rubric (LCJR) and the qualitative questions. Student responses were submitted anonymously. The study was deemed exempt by the University Institutional Review Board.
The LCJR was used for students to self-evaluate their performance postintervention. It was developed using Tanner's IMCJ conceptual model. The LCJR examines students' development of clinical judgment at different points in care. It measures the four components of clinical judgment: noticing, interpreting, reflecting, and responding. Each component is rated on a scale of 1 to 4: 1 = beginning, 2 = developing, 3 = accomplished, and 4 = exemplary. The LCJR tool has been used nationally and internationally. This tool's validity and reliability have been established in studies in nursing education (Cantrell et al., 2021; Lee, 2021; Yang et al., 2019). Consent to use the LCJR was obtained from its creator.
Participants were also asked to complete three qualitative questions: 1.) Describe how the educational experience prepared you for using your clinical judgment in caring for patients in multiple healthcare settings. 2.) What part of the experience had the greatest impact on you? 3.) What else do you feel you need to develop clinical judgment skills?
Step 1: Standardized patients, simulation assistants, and clinical instructors were trained and educated on the simulation objectives and scenarios before implementation.
Step 2: The simulation director read the recruitment script and informed consent was obtained on the day of the simulation. Students were informed that if they consented to the study, they would be asked to complete anonymous surveys at the end of the simulated experience. In addition, students were informed the presimulation work, simulation, and debriefing were required coursework.
Step 3: Students completed presimulation work consisting of guided questions to ensure they understood type 2 diabetes.
Step 4: After reviewing the presimulation work with their clinical instructor, the simulation director reviewed the objectives of the simulation and oriented the students to the three settings: primary care office, acute care patient room, and the patient's home.
Step 5: Simulation. Standardized patients and a high-fidelity simulator were utilized for this study. Students attended the simulation in groups of 5 to 8 students with their clinical instructor and were assigned to one of the three scenarios and various roles. Two or three students participated in each scenario and the students who were not participating observed the simulation via video and completed observation forms. This allowed them to see the scenario's progression and participate in peer feedback during debriefing. The first scenario introduced the students to the patient, who needed education on a new diagnosis of type 2 diabetes, including glucose monitoring and insulin administration. The second scenario involved the patient admitted for hyperglycemia in an acute care setting. In this scenario, students were expected to recognize the clinical manifestations of hyperglycemia and reinforce the diabetes education taught in the primary care office. The third scenario consisted of a skilled nursing visit to evaluate the patient in the home setting 3 days post discharge from the acute care hospitalization. In this scenario, students were exposed to additional concerns including a cluttered home environment, the patient's struggle with storing insulin, disposal of insulin syringes, and multiple candy wrappers in the home. Although the patient verbalized understanding of the education in the previous healthcare settings, she was struggling with doing it at home and felt overwhelmed. Students needed to engage community resources including a meal delivery service to assist the patient. The patient's progression through these three settings allowed students to understand the different challenges patients face as they manage chronic disease.
Step 6: Students were debriefed using the Debriefing with Good Judgment Model (Rudolph et al., 2007). This model focuses on learner reactions, analysis, and a summary of the simulated experience. Debriefing was done with the entire group after each scenario, including student participants, observers, and standardized patients.
Step 7: After the simulation experience, students completed the LCJR and answered the qualitative questions in a private room without the presence of faculty or staff. Their responses were submitted without identifying information.
Quantitative data were analyzed and managed using the SPSS version 24. There were no missing data. Using content analysis, both researchers independently read participants' responses to the qualitative questions to identify preliminary codes that supported the development of distinct categories. The synthesis of categories and clarification of discrepancies were based on the recommendations of Creswell (2018).
Quantitative. All 91 undergraduate nursing students completed the surveys. Descriptive statistics were used to calculate the mean of each category of the LCJR tool given postintervention. The LCJR has four major components with a total of 11 subcategories. For the 11 subcategories, the mean ranged from 3.17 to 3.68, suggesting participants scored themselves as accomplished after the intervention in their clinical judgment skills.
Qualitative. Four themes emerged from the content analysis: 1.) increased knowledge of management of diabetes in various clinical setting; 2.) using clinical judgment/critical thinking in the hospital, and home care settings; 3.) being able to self-reflect on actions; 4.) a desire for more simulation experiences in home care settings.
Theme 1 - Increased knowledge of the management of diabetes in various clinical settings
Students thought the educational experience helped increase their knowledge of diabetes management and patient education in various healthcare settings. The students commented that managing a patient's diabetes in the home setting was vastly different from the acute care setting, including using different assessment skills such as assessing the home environment.
“This prepared me by exposing me to different environments, which made me look at the whole picture rather than just the patient in the hospital.”
“The patient had her diabetes and physical health under better control in the home care setting but struggled more with her mental health. This helped me see a different side of nursing with different teaching points.”
“The experience was very helpful. I feel that I was able to fully help the patient understand the education and importance of that with diabetes. This includes insulin, nutrition, exercise, and safety and how it was different in the home care setting.”
“The experience sets you with different scenarios relating to real-life situations to help you collect data, observe, and react to the situation in different settings, in a non-judgmental environment.”
Theme 2 - Using clinical judgment/critical thinking in the hospital and home care settings
Students described needing to use clinical judgment to respond to changes in the patient's condition and circumstances and to prioritize care. They recognized they needed to demonstrate different clinical judgment skills as the unfolding scenarios progressed.
“The educational experience allowed me to use my critical thinking skills to evaluate what is wrong with my patient and what I should prioritize in each scenario.”
“The home health setting was challenging. We did not have the same resources as in the hospital. It made me use my critical thinking in a different way.”
“It gave real-life situations and allowed me to use our clinical judgment skills in different settings.”
“Unexpected deviations made me think critically and fast!”
Theme 3 - Being able to self-reflect on actions
Students indicated the debriefing after each scenario and at the end of the simulation was beneficial. They described learning from their peers and being able to reflect on needed improvements in a safe environment. This feedback contributed to the student's ability to use clinical judgment skills to respond to changes in the patient's condition. Students could also discuss their frustration with family members creating barriers to the patient participating in the treatment plan.
“I think the discussions after the simulations were good because we were all able to give different views and ideas and talk about what to do in each scenario, including improvements.”
“Being able to watch other groups and reflect on our actions”
Theme 4 - A desire for more simulation experiences in various healthcare settings
Students expressed a desire to have more simulations throughout the curriculum. They stated that specific simulations allowed them to practice skills to a greater extent than in the acute care setting. They also emphasized a desire for more home care simulations.
“More simulations! Clinical is amazing but with specific scenarios like today, I feel like I am learning a lot.”
“More practice with simulation and real patient/family/caretaker interactions in the home care setting.”
“I can't wait to do more sims! This is a comfortable, non-threatening way to practice and learn our skills.”
Discussion and Implications
As evidenced in the literature and by recommendations from nurse leaders, undergraduate nursing students need educational experiences to build and strengthen clinical judgment skills. In addition, as the demand for home healthcare nurses increases with more healthcare being delivered in the home, we need to expose nursing students to this healthcare setting. Attaining clinical sites in home healthcare is challenging. Simulation is an established, effective teaching strategy to meet the need for improved clinical judgment skills and exposure to healthcare settings outside the acute care setting. However, a specifically designed simulation allowing students to demonstrate their clinical judgment skills in different healthcare settings added depth and value to their learning experience. It also allowed the students to learn and experience the importance of patient education and continuation of that education in multiple healthcare settings over time. The use of lectures, presimulation work, simulation, and debriefing allowed students to assimilate knowledge and clinical judgment skills needed to provide quality care to a patient with a chronic illness. The results of the LCJR indicated that students felt accomplished after the learning experience. This outcome also emerged 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. It also revealed the home healthcare setting had the greatest impact as they had to use different clinical judgment skills to educate and help the patient.
This simulation intervention was conducted with a convenience sample of nursing students from a single school, limiting generalizability. Although the answers to the qualitative questions were collected anonymously, it is possible students answered in a way that reflected how they thought the faculty wanted them to respond.
It is imperative that nursing students participate in learning activities to enhance their clinical judgment skills in multiple healthcare settings. Simulation is a learning experience designed to allow students to develop and utilize their clinical judgment skills while providing patient care in a safe environment.
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