clinical judgmentmiclinical reasoningare the student outcomes of long-lauded prelicensure nursing education programs. As nursing and healthcare evolved, these keywords were increasingly incorporated into our curriculum design, competency lists, syllabi, accreditation manuscripts, and standards of practice. But after all, what is clinical judgment? What is it, how do we help students develop it, and how can we measure it as a result?
What is clinical evaluation?
If you were to ask five experienced caregivers this question, you would probably get five different answers, and they could all be correct! Many efforts have been made to define the phenomenon of clinical judgment, and several different models exist (Cappelletti et al., 2014; Manetti, 2019). Recently, clinical judgment has become the focus of our licensure exams such as the National Council of State Boards of Nursing (NCSBN, 2019) Clinical Judgment Assessment Model. Nurses' mental response to clinical cues has now been broken down into discrete steps in this clinical judgment measurement model:
(https://www.ncsbn.org/14798.htm)
The layered model breaks down the steps a nurse must follow to decide the appropriate clinical responses to clients' needs. Essentially, clinical judgment in nursing requires the nurse to recognize and apply signs that a problem exists.critical thinkingrespond to these signals. The steps of the Clinical Judgment Measurement Model include (NSCBN, 2019):
- Formulation of hypotheses: The nurse must interpret the most relevant information in the context of the patient's clinical condition.
- Refine hypotheses: the caregiver needs to refine the hypotheses considering which are the most probable, the most urgent, or the most risky. The caregiver can then generate solutions to address the priority problem.
- Evaluation: After implementing the interventions to address the priority problem, the nurse re-evaluates the scenario and compares the observed result with the expected result. This process is then repeated as necessary.
With experience, this thought process becomes less structured and more fluid. As nurses progress from novice to expert, their actions are governed less and less by rigid principles and rules (Benner, 1984). Nurses working at a higher level of competence act according to the context of each specific situation. This clinical judgment can only be acquired through practical nursing experience. While this expert-level practice may seem very different from the level of a freshman struggling to learn drug suffixes, it's never too early to help your students hone their clinical judgment.
How can I help my students develop clinical judgment?
How can we help our students develop clinical judgment when they only have a fixed and limited number of clinical hours to deal with patients? While there is no substitute for hands-on nursing experience, there are several strategies that help us increase the "return" of learning with students' limited clinical hours. Two proven strategies to stimulate the development of clinical judgment are high-fidelity simulation and guided reflection (Cappelletti et al., 2014).
Simulation
Simulation is not a true substitute for the bedside experience, but simulated learning experiences can be designed to include the same cues and conditions as the clinical setting. Simulated learning activities can also be introduced into the curriculum at optimal times to reinforce student learning, while clinical encounters are largely random and may require knowledge of diseases and therapies that students are not familiar with. have been previously exposed. Furthermore, simulation offers the advantage of having a safe and controlled environment in which students can practice clinical assessment without risk of harm to patients. These advantages make simulation an ideal environment to allow for errors and growth.
But the simulation is more than just bedside practice. Careful and intentional simulation design must prioritize ample opportunities for student reflection and engagement. As with any learning activity, the objectives must be clearly defined in a simulation pre-briefing (Al Sabei & Lasater, 2016). Although simulation design is time consuming, relatively little attention is paid to the design of a structured report. This is unfortunate, as the student's ability to transfer learning from simulation to actual clinical practice is highly dependent on the quality of the post-simulation report.
Ideally, teachers should focus on the debriefing as the focus of the simulation activity and be prepared to spend twice as much time on the debriefing as they do on the simulated encounter (Al Sabei & Lasater, 2016). For example, an hour-long simulation exercise might start with 20 minutes of actual simulation and a full 40 minutes of detailed information. During the debriefing, a facilitator should guide students to reflect on their observations, insights, and feelings that they experienced during the activity. The more actively the student participates in the simulation, the more learning is reinforced. The National League for Nursing (2019) provides a simulation design template with 21 open-ended questions designed to stimulate reflection in reporting.
guided reflective writing
Unlike high-fidelity simulations, now widely used in nursing education, guided reflection as a learning exercise remains a relatively untapped resource. Nursing students first learn nursing as a context-independent set of rules and principles for delivering nursing services. However, this does not effectively prepare them for the practice setting, where any clinical assessment requires consideration of the context and setting of the patient as a whole. Guided reflection, whether through individual journals, group discussions, or a graded reflective writing exercise, has been shown to help students integrate theoretical nursing knowledge with real-world experiential knowledge (Benner, 1984).
For example, in exercises based on Tanner's (2006) clinical judgment model, a student might be asked to describe what they noticed about the patient.First, then asked in a follow-up notice what they noticed about the patientlaterin daily clinical practice (Smith, 2021). Otherwise, these nuanced aspects of a novice assessment would get buried and lost in a traditional clinical treatment planning task, where all information is treated equally and placed under the umbrella of "assessment." Structuring or directing students' reflection in this way leads them to describe how a situation evolved, how their understanding of the situation evolved during the clinical task, and how they did or did not choose their chosen course of action for alternative measures (Benner et al. , 2009).
While we believe we provide students with ample opportunity for reflection in post-clinical lectures and mock reports, we do have individual reflection activities such as student step-by-step clinical learning. Engaging nursing students in a guided reflective journaling exercise allows educators to ask questions that go beyond the instructions of a traditional "nursing plan."
other strategies
Developing case studies similar to those used in NCSBN's Next Generation NCLEX® (2020) can be used in the classroom or even as a kind of virtual simulation experience suitable for socially distanced classrooms when face-to-face learning is not possible (Jeffries et al.al., 2016). Practicing with NCLEX®-style question banks already provides built-in feedback in the form of an explanation or justification for a question. Students can further enhance their hands-on learning using the Question Bank, using the 'Notes' features to record their reflections on the clinical scenario presented.
If you're not ready to review your students' courses yet, consider incorporating a low-stakes assignment once a semester in which the student thinks about a specific patient or situation (simulated or real) that makes them stand out. Any weight or criteria given to such an assignment must be specific enough to encourage full reflection, but not threatening, so that the student can feel safe thinking openly about their learning experience. Incorporate this task regularly and enjoy watching your young nurses hone their skills in the holistic judgment, clinical reasoning, and even the intuitive wisdom that contributes to sound clinical judgment.
UWorld Nursing Learning PlatformIt was developed by nursing educators and nurse practitioners to develop critical thinking and critical thinking skills. Assignable questions, detailed answer explanations, descriptive illustrations and images, and performance tracking not only improve a program's NCLEX-RN or NCLEX-PN pass rates, but also increase student confidence, increase learning opportunities and help nurture the next generation of nurses for a secure, accurate and rewarding career in nursing. And now you have the option to create presentations or assignments using state-of-the-art case studies, traditional questions, or a combination of both.
If you have any questions or would like to see a personal demo of UWorld's Nursing Learning Platform, please contact us.[Email protected].
references
Al Sabei, SD and Lasater, K (2016). Simulation debriefing for the development of clinical judgment: a conceptual analysis.nursing education today,45, 42–47.https://doi.org/10.1016/j.nedt.2016.06.008
Benner, P. (1984).From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison-Wesley.
Benner, P., Tanner, C. y Chesla, C. (2009).Nursing Practice Expertise: Care, Clinical Judgment, and Ethics(2nd ed.). bridge.
Cappelletti, A., Engel, J.K. and Prentice, D. (2014). Systematic review of judgment and clinical reasoning in nursing.The Journal of Nursing Education,53(8), 453-458.https://doi.org/10.3928/01484834-20140724-01
Jeffries , P.R. , Swoboda , S.M. and Akintade, B. (2016). Teaching and learning with simulations. In D. M. Billings and J. A. Halstead (Eds.).Teaching in Nursing: A Guide for the Faculty(5th ed., pp. 304–323). Elsevier.
Manetti, W. (2019). Good clinical judgment in nursing: a conceptual analysis.care forum,54(1), 102–110.https://doi.org/10.1111/nuf.12303
National Council of State Nursing Councils. (2019). Clinical evaluation measurement model and performance model.Next Generation NCLEX News,spring 2019, 1–6.https://www.ncsbn.org/NGN_Spring19_ENG_29Aug2019.pdf
National Council of State Nursing Councils. (2020). NGN-Fallstudie dies.Next Generation NCLEX News,Primavera 2020, 1–7.https://www.ncsbn.org/NGN_Spring20_Eng_02.pdf
National League of Nursing. (2019, May).mockup design template. Retrieved on January 10, 2022 fromhttp://www.nln.org/docs/default-source/professional-development-programs/sirc/simulation-design-template-2019newlogo.docx?sfvrsn=8
Smith, T. (2021). Guided reflective writing as a didactic strategy to develop clinical judgment in nursing students.care forum,56(2), 241–248.https://doi.org/10.1111/nuf.12528Tanner, CA (2006). Thinking like a nurse: a research-based clinical judgment model in nursing.Nursing Education Journal,45(6), 204-211.https://doi.org/10.3928/01484834-20060601-04