Clinical judgment is key to clinical decision-making and safe patient care.1–3 Learning to make sound clinical judgments begins during nursing education and continues as students transition into practice.4–6 New graduate nurses often lack confidence in their decision-making skills and have difficulty recognizing and responding to patient complications.1,5,6 Thus, a gap exists between the clinical judgment competency necessary for practice and the actual competency level of new nurse graduates. In response, the National Council of State Boards of Nursing (NCSBN) has developed a plan to measure clinical judgment on the NextGen nursing licensure examination beginning in 2023.2 These impending changes have created increased urgency for prelicensure educators to understand best practices in teaching clinical judgment.4,7,8
Background
Developing clinical judgment is a process that involves time and experience, deliberate support, and scaffolding of teaching activities so that students develop the needed skill set to enact clinical judgments.9,10 A variety of approaches have been described to teach clinical judgment in nursing including simulation,10–12 online technology/virtual simulation,13 case studies,14 questioning strategies,8,13 concept-based learning activities (CBLAs),8,15 concept mapping,16,17 feedback,8,13 and structured reflection.5,6,18,19 An integrative review of clinical reasoning found that various teaching strategies increased clinical reasoning skills, but only if the approaches were framed by a model.10 While the body of literature describing approaches to teaching clinical judgment is growing, there is limited comprehensive foundational evidence about exactly what strategies are being used currently for teaching in nursing schools across the United States.
The research described in this article was part of a larger project designed to provide foundational evidence for how US prelicensure nursing programs are using clinical judgment models and teaching strategies to promote development of students' clinical judgment. The findings about model use have been described elsewhere20 and identified that only 27% of deans and directors surveyed reported that their schools currently use a model to teach clinical judgment. Of the schools not currently using a model, 72% indicated that they intended to start whereas 28% indicated that they did not intend to start.
Purpose
This article reports teaching strategies used to promote students' clinical judgment and deans' and directors' beliefs about them. Specific aims for this part of the study were to (1) describe the types of teaching strategies used to promote student development of clinical judgment and (2) explore dean/program director beliefs about how their use or nonuse of teaching strategies to guide student development of these skills is influencing student outcomes.
Methods
Design and Setting
The study used a cross-sectional survey methodology to explore the prevalence of use and beliefs about clinical judgment teaching strategies by prelicensure RN education programs throughout the United States. The survey instrument included multiple-choice, yes/no questions and open-text responses. Study participants were selected from the target population of all deans/program directors of US prelicensure RN nursing programs identified by inclusion on the approved NCSBN Active Educational Program Codes.21 The research was approved as exempt by the institutional review board at the university where the primary investigator is a faculty member.
Survey Development
The survey was developed by a group of researchers with significant experience related to clinical reasoning and judgment. Survey items were designed to elicit practices in model use (described elsewhere20), teaching strategy use for the specific purpose of developing clinical reasoning and judgment (response options listed in the Table), and beliefs about how the choice to use or not use teaching strategies to promote clinical reasoning and judgment is influencing student outcomes.
Sample Description and Data Collection Procedure
The study purpose, participant confidentiality, survey access, and the primary investigator's contact information were emailed to 2589 deans/directors of US RN prelicensure education programs meeting the inclusion criteria. Participants were able to access the survey using REDCap (Research Electronic Data Capture) secure web application 1 week after receiving the initial email. The survey instrument was made available to all participants for 4 weeks. Reminder emails including the purpose of the study and instructions related to survey access were sent to nonresponding participants each week during the survey open access period.
Data Analysis
Quantitative
The results were analyzed to describe the use of teaching strategies in nursing programs. The acceptable response size (n = 237) was calculated using the following variables: population size (n = 2589), confidence level (90%), and margin of error (0.5). The unique nature of the study and the reduced risk of making type I or type II errors on public safety allowed the researchers to set the confidence level at 90%. The generalizability of the distribution of the program types in the sample to the distribution of program types in the population was determined using Z-score analysis of proportions in the following populations: bachelor of science in nursing (BSN), associate degree in nursing (ADN) diploma, master of science in nursing (MSN)/doctor of nursing practice (DNP) entry to practice, BSN entry to practice, and Other. For reporting purposes, the number and types of teaching activities used were analyzed by model use status, as described in the article reporting first results of the larger study.20
Qualitative
A qualitative research expert who was not part of the research team conducted a preliminary analysis of the data for differences among program types and use or nonuse of a clinical judgment model, identified codes, and proposed themes. Members of the research team separately coded and categorized the data. Through iterative rounds of data analysis, themes identified by the qualitative research expert were reconciled with those identified by the research group, resulting in collapsing some themes into larger ones, and creation of subthemes. Consensus was reached and final themes were agreed upon by the research group and confirmed with the qualitative expert.22
Results
Quantitative Results
Z-score analysis of findings suggests that stratified generalizability of BSN/ADN sample responses to the BSN/ADN population is acceptable and specific results are reported for those 2 groups. Generalization of the findings to other program types should be done with caution. All schools reported using at least one strategy to teach clinical judgment. The number of strategies used ranged from 1 to 9; the median number was 6 for ADN programs, 7 for BSN programs, and 99.6% of all programs reported using multiple strategies. Of all schools surveyed, 98% use case studies to teach clinical judgment, 97% use simulation, 81% use online virtual technology or simulation, and 77% use questioning (Table). Schools also used concept mapping (70%), feedback (68%), structured reflection (55%), coaching (47%), and concept-based learning (39%). There were no significant differences among categories of model use or program type (BSN or ADN) and the number or type of teaching activities used.
Table. -
Teaching Activities Used
|
Average Among All Schools, % |
Currently Using a Model, % |
Intend to Start Using a Model, % |
Do Not Intend to Start Using a Model, % |
ADN Programs,% |
BSN Programs,% |
| Case studies |
98.34 |
96.97 |
98.36 |
100.00 |
97.67 |
99.05 |
| Simulations |
96.68 |
93.94 |
96.72 |
100.00 |
96.12 |
97.14 |
| Virtual technology |
80.91 |
75.76 |
81.97 |
84.00 |
82.17 |
81.90 |
| Questioning |
76.76 |
80.30 |
77.87 |
70.00 |
75.19 |
80.95 |
| Concept mapping |
70.12 |
66.67 |
71.31 |
74.00 |
75.19 |
66.67 |
| Feedback |
67.63 |
65.15 |
66.39 |
74.00 |
68.99 |
66.67 |
| Structured reflection |
54.77 |
56.06 |
54.92 |
52.00 |
46.51 |
66.67 |
| Coaching |
46.89 |
62.12 |
42.62 |
38.00 |
45.74 |
50.48 |
| Concept-based learning |
38.59 |
48.48 |
32.79 |
38.00 |
44.19 |
30.48 |
| Other |
3.32 |
3.03 |
3.28 |
4.00 |
1.55 |
5.71 |
|
n = 241 |
n = 66 |
n = 122 |
n = 50 |
n = 129 |
n = 105 |
Abbreviations: ADN, associate degree in nursing; BSN, bachelor of science in nursing.
Qualitative Results
Four main themes emerged regarding participants' beliefs about the outcomes of teaching strategy use: student outcomes, program outcomes, implementation of teaching for clinical judgment, and reservations about teaching clinical judgment (see Supplemental Digital Content, Table, available at: https://links.lww.com/NE/B162). Subthemes are italicized in the following sections.
Theme 1: Student Outcomes of Clinical Judgment Teaching Strategies
Positive student learning outcomes of teaching for clinical judgment were strongly emphasized by participants. The largest number of comments was in the subtheme of development of student thinking/decision making for safe patient care. Participants described increased student confidence, engagement, deeper understanding, and ability to apply concepts and reasoning. One participant noted, “Teaching-learning strategies to promote judgment are a critical part of our BSN program. It strengthens the learner in decision making for positive patient outcomes.”
Participants described practice readiness as a key outcome of teaching for clinical judgment. One participant stated, “Our graduates verbalize that they feel prepared for the clinical setting.” Another stated, “Our use of sound pedagogy to foster clinical judgment ensures our graduates are not only NCLEX ready but also practice-ready.... Employer feedback reflects the [impact of] intentional integration of strategies to enhance clinical judgment.”
Theme 2: Program Outcomes of Clinical Judgment Teaching Strategies
Several participants believed that teaching strategies for clinical judgment resulted in NCLEX success. One respondent said, “When we did not have [clinical judgment] learning strategies, our NCLEX pass rates were lower.... We saw an increase in NCLEX [scores] after adding more learning methods.” Other program outcomes mentioned by participants included stakeholder/employer satisfaction, student retention, and general positive outcomes related to teaching clinical judgment. One participant summarized, “Our outcomes speak for themselves—excellent board pass rates, excellent program retention, and a community with an excellent appetite to hire our grads.”
Theme 3: Implementation of Teaching Strategies to Promote Clinical Judgment
Participants discussed the importance of consistency, frequency, and deliberateness in the approach to teaching, as well as threading clinical judgment content throughout the program. Connections between diverse student development trajectories and repeated exposure to clinical judgment, with links to model use, were made. Alignment of best practice teaching strategies was recommended. Effective teaching approaches included making the clinical judgment process clear and then guiding students through it. One participant noted, “The lack of a consistent model to promote judgment leads to mixed messages to students from faculty and that level of clinical reasoning/judgment may be lower than if we utilized a model.” The impact of educator approach to teaching for clinical judgment was noted. According to a participant, “The expertise of the nursing faculty plays an important role in the choice as well as the quality implementation of any chosen strategy to teach clinical judgment.”
Participants also discussed the importance of using diverse approaches to support learning needs. They noted that students learn in different ways and develop at different rates and that a wide variety of strategies are needed. One participant said,
Applying multiple strategies helps us reach the diverse learning needs of our students—this iterative process ... reinforces the importance of clinical reasoning/judgment—all strategies employed rely on an interaction between the teacher-learner, thereby fostering development of reasoning and judgment over time.
Other teaching approaches included integration of clinical practice into theory and evaluation strategies. Participants described using knowledge in a safe setting such as simulation. “Rather than memorizing, they are learning concepts and how to apply to a variety of situations.” One participant described evaluation this way,
Use of teaching learning strategies ... provides a way to get a “snapshot” of how the student is thinking and processing information [about clinical judgment] ... and provides insight into how to adjust teaching methods to meet the students' learning needs.
Another participant spoke to the moral imperative of teaching for clinical judgment, “Students must be able to critically think and use their clinical judgment skills to be a nurse. It is our educational duty to make sure we teach them how to develop these skills.”
Theme 4: Reservations About Teaching Clinical Judgment
Although only 8 participants mentioned reasons for not adopting specific clinical judgment teaching activities; this theme is included to capture diverse perspectives. Content overload, doing well without changes, lack of need, previous lack of success adding content, and logistical issues were the reasons identified for not adopting teaching activities.
Discussion and Recommendations
Learning Activity Use and Evidence Base
This study found that multiple strategies commonly described in the literature are currently used to promote clinical judgment development. Case studies, virtual technologies, and simulation were the top 3 teaching strategies used by educators. Interestingly, participants completed the survey during the height of the pandemic. Virtual simulation use increased during the pandemic and may promote thinking similarly to in-person simulation.11,23 Teaching with case studies is valued broadly for facilitating thinking about patient care in the classroom.10,14 Simulation is widely used to promote development of thinking and clinical judgment in practice situations.10,11,24 Furthermore, it can help students identify salient information and recognize patterns that lead to problem identification.11 Debriefing and reflection used alongside simulation enrich learning experiences and foster clinical judgment.11,24
Interaction with faculty, including questioning, clinical coaching, and feedback, supports integration of knowledge and action and mentors students' thinking to enhance clinical judgment.4,8,13,14,25 Use of a model to guide questioning and discussion with learners may identify misunderstandings that lead to breakdowns in clinical judgment.5 Clinical coaching using higher-level questioning around application of knowledge, analysis of subtle distinctions in patient situations, and evaluation of possible interventions is recommended.4 Similarly, prebriefing prior to clinical experiences26 and role modeling13 develop clinical judgment.
Reflection is one of the most frequently described strategies for supporting development of clinical reasoning in the literature,10 yet only 55% of participants identified it as a strategy used at their schools, which may be a missed teaching opportunity. Using the structured components of clinical judgment to prompt student analysis of situations makes their thinking visible and solidifies learning.5,6,18,19 Likewise, journaling allows faculty to understand and evaluate student thinking about care.8,18 Concept mapping fosters student integration of salient clinical information into care plans,16 recognition of relationships among ideas, and integration of theory and practice.17
At 39%, concept-based learning was the least used strategy among responding schools. CBLAs, used during clinical experiences, focus thinking on one key aspect of the patient situation without responsibility for total patient care, integrate theory knowledge into practice, support development of salience and pattern recognition, and have been shown to develop clinical judgment.8 CBLAs have been used to frame all clinical experiences in a medical-surgical clinical course, introducing and developing a new clinical reasoning theme each week.15 This is one of the few strategies described in the literature for teaching clinical judgment in practice settings.
Outcomes of Teaching Strategies for Clinical Judgment
Participants emphasized the value of teaching for clinical judgment on development of student thinking and readiness for practice, as well as positive program outcomes, including NCLEX pass rates. Increased discussion about clinical judgment nationally along with increased production of proprietary products to teach it since the announcement of NextGen NCLEX creates opportunities to improve teaching and learning clinical judgment. Clinical judgment spans the nursing program and NCLEX, thus educators should not view the NCLEX as the final goal. Beginning with awareness of desired practice competencies in clinical judgment, educators can plan teaching and assessment that foster and ensure those competencies are met. Focus on teaching to develop clinical judgment competence shifts the focus to the primary goal of improved patient care.
Implementation of Teaching for Clinical Judgment
The participants provided implementation advice for clinical judgment teaching activities. Many of their recommendations are common best practices in teaching and can be supported by consistent use of a model. Repeated exposures to learning experiences are needed to support clinical judgment growth.8,9,12,24 Use of a model helps unify the approach to teaching clinical judgment among individual faculty and across the curriculum.8,27 A model provides common language to discuss clinical judgment; supports scaffolding, assessment, and feedback adapted to developmental stages13; and can frame design of effective teaching activities for clinical reasoning and judgment.10,27 We should address barriers to implementation of teaching strategies including content overload and perceived lack of need to make change and then develop faculty ability to implement teaching and learning grounded in clinical judgment.27
Emerging in the literature are reports of using the NCSBN Clinical Judgment Measurement Model (CJMM)28 as a framework for teaching.27 The CJMM incorporates elements of 3 models and multiple factors known to influence clinical judgment in layers with the aim of clinical judgment measurement. The authors of the model have clarified that the model is intended for high-stakes testing and measurement and not specifically teaching.29 Careful review of options and deliberate selection of a teaching model that is a good fit for the nursing program are recommended.
Future Work
A Call for More Research
Literature describing teaching clinical judgment is plentiful within the last 15 years, with publications accelerating as implementation of the proposed NextGen NCLEX approaches. While many teaching-learning strategies have been described, few publications use a research-based approach to determine efficacy of the strategies. Although concerns about new graduate readiness for practice exist,30 there is little research-based evidence about new graduate competence in clinical judgment. More formal research on the efficacy of teaching strategies, including clinical teaching approaches, and model use, with clear measurement of clinical judgment development both pre- and postlicensure, is needed.4,31
Academic-Practice Partnerships
It has been suggested that primary responsibility for developing clinical judgment is with prelicensure educators.30 Development of clinical judgment occurs on a continuum that extends beyond formal education. Academic-practice partnerships are paramount to development of a firm foundation during the nursing program that is supported as new nurses transition into practice.6 Joint understanding of development of and teaching for clinical judgment will support the continuum of learning across the academic-practice transition. Defining clinical judgment competency outcomes at the end of nursing programs will help employers understand how best to build upon the process begun in nursing education programs.
Conclusion
Teaching for clinical judgment development has never been more important. Schools of nursing are using strategies to teach clinical judgment, whether or not they have adopted a specific model within their curriculum. This study demonstrated that there are more similarities than differences in how ADN and BSN programs are using teaching strategies, and many programs are using multiple strategies. Deans and directors believe teaching for clinical judgment improves student thinking, practice readiness, success on the current NCLEX, and employer satisfaction. The need for consistency, deliberateness, and alignment of best practices underscores the importance of faculty development for teaching clinical judgment. While it is tempting to focus on teaching clinical judgment to ensure success on the NextGen NCLEX, the focus must remain on preparing students for safe nursing practice. As nurse educators, we must reflect on our current state, consider necessary changes for teaching and learning, and plan to move forward with creativity, collaboration, and further research.4,20
References
1. Lavoie P, Clarke SP, Clausen C, et al. Nursing handoffs and clinical judgments regarding patient risk of deterioration: a mixed methods study. J Clin Nurs. 2020;29(19/20):3790–3801. doi:10.1111/jocn.15409
2. National Council of State Boards of Nursing. Next Generation NCLEX Project. Accessed January 3, 2022.
https://www.ncsbn.org/next-generation-nclex.htm
3. Tanner C. Thinking like a nurse: a research-based model of clinical judgment. J Nurs Educ. 2006;45(6):204–211. doi:10.3928/01484834-20060601-04
4. Jessee MA. An update on clinical judgment in nursing and implications for education, practice, and regulation. J Nurs Regul. 2021;12(3):50–58. doi:10.1016/S2155-8256(21)00116-2
5. Monagle JL, Lasater K, Stoyles S, Dieckmann N. New graduate nurse experiences in clinical judgment: what academic and practice educators need to know. Nurs Educ Perspect. 2018;39(4):201–207. doi:10.1097/01.NEP.0000000000000336
6. Wright J, Scardaville D. A nursing residency program: a window into clinical judgment and clinical decision making. Nurse Educ Pract. 2021;50:102931. doi:doi:10.1016/j.nepr.2020.102931
7. Bristol T. Next Gen learning for the new National Council Licensure Examination for Registered Nurses. Teach Learn Nurs. 2019;14(4):309–311. doi:10.1016/j.teln.2019.06.009
8. Gonzalez L, Nielsen A, Lasater K. Developing students' clinical reasoning skills: a faculty guide. J Nurs Educ. 2021;60(9):485–493. doi:10.3928/01484834-20210708-01
9. Ashley J, Stamp K. Learning to thinking like a nurse: the development of clinical judgment in nursing students. J Nurs Educ. 2014;53(9):519–525. doi:10.3928/01484834-20140821-14
10. Tyo MB, McCurry MK. An integrative review of clinical reasoning teaching strategies and outcome evaluation in nursing education. Nurs Educ Perspect. 2019;40(1):11–17. doi:10.1097/01.NEP.0000000000000375
11. Cantrell MA, Franklin A, Leighton K, Carlson A. The evidence in simulation-based learning experience in nursing education and practice: an umbrella review. Clin Simul Nurs. 2017;13(12):634–667. doi:10.1016/j.ecns.2017.08.004
12. Theobald KA, Tutticci N, Ramsbotham J, Johnston S. Effectiveness of using simulation in the development of clinical reasoning in undergraduate nursing students: a systematic review. Nurse Educ Pract. 2021;57:103220. doi:10.1016/j.nepr.2021.103220
13. Deschenes M, Goudreau J, Fontaine G, et al. Theoretical foundations of educational strategies used in e-learning environments for developing clinical reasoning in nursing students: a scoping review. Nurs Educ Pract. 2019;41:102632. doi:10.1016/j.nepr.2019.102632
14. Vacek J, Liesveld J. Teaching concepts to nursing students using model case studies, the Venn diagram, and questioning strategies. Nurs Educ Perspect. 2019;41(6):373–375. doi:10.1097/01.NEP.0000000000000514
15. Gonzalez L. Teaching clinical reasoning piece by piece: a clinical reasoning concept-based learning method. J Nurs Educ. 2018;57(12):727–735. doi:10.3928/01484834-20181119-05
16. Eisenmann N. An innovative clinical concept map to promote clinical judgment in nursing students. J Nurs Educ. 2021;60(3):143–149. doi:10.3928/01484834-20210222-04
17. Garwood J, Ahmed A, McComb S. The effect of concept maps on undergraduate nursing students' critical thinking. Nurs Educ Perspect. 2018;39(4):208–214. doi:10.1097/01.NEP.0000000000000307
18. Brown LG, Briscoe G, Grabowsky A. The influence of journaling on nursing students: a systematic review. J Nurs Educ. 2022;61(1):29–35. doi:10.3928/01484834-20211203-01
19. Smith T. Guided reflective writing as a teaching strategy to develop nursing student clinical judgment. Nurs Forum. 2021;56(2):241–248. doi:10.1111/nuf.12528
20. Jessee MA, Monagle J, Nielsen A, Gonzalez L, Dickison P, Lasater K. A national report on clinical judgment model use in pre-licensure nursing curricula. Nurs Educ Perspect. In press.
21. National Council of State Boards of Nursing. NCSBN education program codes list. Accessed August 4, 2021.
https://www.ncsbn.org/NCLEX_Educational_Program_Codes.pdf
22. Merriam S, Tisdell E.Qualitative Research: A Guide to Design and Implementation. 4th ed. Jossey-Bass; 2016.
23. Wyatt T, Baich V, Buoni C, Watson A, Yurisic V. Clinical reasoning: adapting
teaching methods during the COVID-19 pandemic to meet student learning outcomes. J Nurs Educ. 2021;60(1):48–51. doi:10.3928/01484834-20201217-11
24. Klenke-Borgmann L, Cantrell M, Mariani B. Nurse educators' guide to clinical judgment: a review of the conceptualization, measurement, and development. Nurs Educ Perspect. 2020;41(4):215–221. doi:10.1097/01.NEP.0000000000000669
25. Merisier S, Larue C, Boyer L. How does questioning influence nursing students' clinical reasoning in problem-based learning? A scoping review. Nurse Educ Today. 2018;65:108–115. doi:10.1016/j.nedt.2018.03.006
26. Kim H, Ryu S, Jang K. Effect of structured pre-simulation preparation and briefing on student's self-confidence, clinical judgment, and clinical decision-making in simulation. Contemp Nurse. 2019;55(4/5):317–329. doi:10.1080/10376178.2019.1641420
27. Sommer SK, Johnson JD, Clark CM, Mills CM. Assisting learners to understand and incorporate functions of clinical judgment into nursing practice. Nurse Educ. 2021;46(6):372–375. doi:10.1097/NNE.0000000000001020
28. Dickison P, Haerling KA, Lasater K. Integrating the National Council of State Boards of Nursing Clinical Judgment Model into nursing educational frameworks. J Nurs Educ. 2019;58(2):72–78. doi:10.3928/01484834-20190122-03
29. Dickison P, Haerling KA, Lasater K. NCSBN Clinical Judgment Measurement Model clarification. J Nurs Educ. 2020;59(7):365. doi:10.3928/01484834-20200617-02
30. Kavanagh JM, Sharpnack PA. Crisis in competency: a defining moment in nursing education. Online J Issues Nurs. 2021;26(1). Article 2. doi:10.3912/OJIN.Vol26No01Man02
31. Leighton K, Kardong-Edgren S, McNelis A, Foisy-Doll C, Sullo E. Traditional clinical outcomes in prelicensure nursing education: an empty systematic review. J Nurs Educ. 2021;60(3):136–142. doi:10.3928/01484834-20210222-03
