F.A. Davis Teaching Clinical Judgment to Nursing Students

When and How?

TEACHING CLINICAL JUDGMENT TO NURSING STUDENTS

Susan Sportsman, PhD, RN, ANEF, FAAN Managing Director Collaborative Momentum Consulting

The increasing complexity of healthcare Anyone who has been involved in the healthcare delivery system over the last several decades recognizes the increasing complexity of care required in a variety of clinical settings. Novice nurses starting their first jobs must be prepared to care for patients with acute or chronic illnesses that require a multitude of medications. These nurses must manage sophisticated technology; coordinate care across the healthcare continuum; and work collaboratively with many healthcare providers who have different points of view. This is a tall order which new graduates twenty or thirty years ago did not face! As healthcare has become more complicated, nurse educators are increasingly aware that novice nurses must be taught to analyze relevant data in a clinical situation and quickly make decisions that promote the welfare of patients. Whether the intellectual exercise the nurse uses to make decisions is called the nursing process, critical thinking, problem solving, or clinical judgment, the nurse’s role is to keep patients safe, despite the complexity of care.

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Are we preparing nurses for entry into practice? 1. Over the last decade, there has been widespread recognition that students must be prepared for this increasingly complex environment. However, everyone involved in preparing students for practice or helping them transition into various practice settings has wondered if novice nurses were really ready to practice effectively in today’s healthcare environment. Beginning in 2009, the National Council of State Boards of Nursing (NCSBN) initiated an extensive research process to determine better methods to assess the clinical judgment competency of the novice nurse taking the NCLEX exam (https://www.ncsbn.org/sites/ncsbn/exams/next-generation-nclex/ngn-resources.page). The process included an extensive literature review regarding clinical judgment, culminating in a white paper of the findings (https://www.ncsbn.org/public-files/Nursing_Clinical_Decision_Making_A_Literature_Review.pdf). The results of this review included: § 50% of entry-level nurses were involved in practice errors (Smith & Crawford, 2002). § 65% of entry-level nurse errors were related to poor clinical decisions (Brennan et al., 2004). § Only 20% of employers were satisfied with the decision-making abilities of entry-level nurses (Saintsing, et al., 2011). The Next Generation NCLEX® 2. The NCSBN began the Next Generation NCLEX® (NGN) project to find methods to better assess the abilities of new graduates. Central to this project was the development of a new Clinical Judgment Measurement Model (CJMM) designed to clarify steps in the clinical judgment process which should be tested before new RNs can practice. The project also introduced new test items that would more adequately measure clinical judgment competency. The CJMM model defined clinical judgment as a combination of critical thinking and problem solving. The model highlights the steps of the clinical judgment process that can be evaluated. These steps, similar to those in the

nursing process, are: 1. Recognize cues. 2. Analyze cues. 3. Prioritize hypotheses. 4. Generate solutions. 5. Take action. 6. Evaluate outcomes.

The NCSBN website provides detailed information about this work with which all nurse educators should become familiar as the NCLEX-RN and PN exams are changing to address these issues beginning in April 2023 (https://ncsbn. org/clinical-judgment-measurement-model). With the changes in the NCLEX examinations as background, the question becomes what can nurse educators do to adapt to this change?

Strategies for change 3. Because nursing schools have always emphasized clinical experience, faculty and students alike have historically depended on clinical experiences as the primary opportunity to integrate class and laboratory content into care for actual patients. However, multiple factors—increased complexity of patient care, related technological and research findings, consolidation of clinical facilities, the Covid-19 pandemic resulting in burnout of healthcare providers, and record high levels of staff shortages—have all changed the clinical experiences available to students. The current clinical environment alone may not be sufficient to produce nurses with good decision-making skills. The goal of the teaching-learning process is the same: to prepare novice nurses to make effective patient care decisions by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action (or not), and evaluating outcomes (https://ncsbn.org/clinical-judgment-measurement-model). To accomplish this, s tudents must be actively engaged in the learning process, even in classroom instruction . Some instructors may be so charismatic that students sit in rapt attention as they lecture. Most of us, however, do not have that talent so we must integrate other strategies to engage students in our classes. We must provide multiple, coordinated opportunities for using clinical judgment to plan care in a wide range of clinical scenarios, beginning in the very earliest nursing courses, including during class, laboratory opportunities, simulations, and clinical experiences. This type of active learning, or “flipping the classroom” is not new to nursing. However, nurse educators know that students often are lax about reading assigned material, particularly before the class where the topic is discussed. We also know that students today want information provided in small “chunks” and like it best when the instructor “just tells us what we need to know,” preferably in PowerPoint presentations given to them before class. Unfortunately, clinical judgment skills cannot be developed by studying PowerPoints. Memorized facts are not enough to analyze a complex situation. What can we do to encourage students to take the lead in moving from regurgitating knowledge using short-term memory, to integrating knowledge from various sources to make decisions to intervene appropriately in patient care? Use of learning materials 4. Today, published learning materials can help faculty engage students in their own learning. For example, F.A. Davis has developed a suite of products called Davis Advantage that provides material across the RN and LPN curricula to help students learn, apply, and assess their understanding of key content so they are prepared to “think like a nurse” and practice effectively in their first job. (FADavis.com/DavisAdvantage). LEARN Based upon a pre-assessment of students’ knowledge, Davis Advantage provides students with personalized learning assignments that include mini-lecture videos and interactive exercises that reinforce textbook learning and make connections among key concepts. Real-time data and analytics track performance, including time spent on assignments. Students can use these analytics to evaluate their own performances, more efficiently managing their study time and taking responsibility for their own learning. Faculty also have access to these analytics to support student remediation. Use of these resources reduces the faculty’s need to cover every important point in class which provides more time in class to reinforce key concepts, clarify students’ questions, pose discussion questions to broaden students’ thinking, and assist students in thinking through case studies (FADavis.com/DavisAdvantage).

APPLY The Davis Advantage Clinical Judgment Case Studies allow students to apply their knowledge to evolving complex clinical scenarios. These case studies align with the Next Generation NCELX® format and can be assigned individually or used for class discussion. Davis Advantage also provides Personalized Teaching Plans that suggest active learning strategies faculty may implement in classroom or small group situations (FADavis.com/ DavisAdvantage). ASSESS Finally, Davis Advantage provides quizzing assignments that can be used to assess students’ competence in using the content to make clinical judgments in specific patient scenarios. These assignments also allow students to assess their own learning prior to tests or exams. Questions replicate NGN-type questions, preparing students for the type of questions they will see on the NCLEX examination beginning in April 2023 (https://fadavis.com/ davisadvantage). Checklist for Faculty 5. Today’s learning resources make use of technology and educational research to support faculty’s efforts to prepare students for clinical practice in a complex world. What then is the faculty role in improving students’ clinical judgment competencies? 1. Develop clear course, class, lab, and clinical learning objectives which emphasize application of knowledge in clinical situations beginning in the earliest nursing courses. In the past, objectives in early nursing courses required students to remember or understand a topic—the objective did not require application to a clinical scenario until later in the curriculum. For example, an objective such as “List the potential causes of decubital ulcers” might appear in a Nursing Fundamentals course. In a perfect world where the time needed to become clinically competent was easily available, perhaps the luxury of requiring application in courses later in the curriculum after students had built some clinical knowledge would be possible. Unfortunately, time is of the essence today, so we must give students an opportunity to apply simple concepts immediately as they are presented. An objective that captures this approach in that Fundamentals course might be “Assess a patient for the potential for developing a decubitus ulcer.“ 2. To the extent possible, provide a clinical context to all lab activities. Simulation activities have taught us that presenting a clinical situation makes the practice of a procedure more real (thus more engaging). So even if the student is to practice a dressing change on a moulage without a simulated patient, the faculty can provide a clinical context that can direct the student’s action. For example, the instructor observing the practice session might say “The patient is experiencing acute, severe pain. What should the student performing the dressing change do?” 3. Clinical Instructors should incorporate questioning that helps students go beyond the application of protocols to those that help students integrate scientific knowledge into clinical judgment. Tanner (2006) suggests that time spent in clinical teaching may be inefficient. Clinical time is often spent in assessing the amount of time students spend in preparing for the clinical experience, supervising assessments, and assuring care is safe (in Van Graan, et al., 2016). While time spent in these tasks is important, (especially ensuring patient safety), helping students go beyond protocols to integrate scientific knowledge and clinical judgment into specific actions is also important. Table A provides an example of questions that can help a beginning student to make these connections.

Table A: Questions to Connect Scientific Understanding and Clinical Judgment The clinical instructor is helping a beginning student empty a foley catheter bag, which is filled with dark, concentrated urine. Questions the instructor might ask the student, at the appropriate time, include:

1. How would you describe this urine?

2. What is the physiological reason for the appearance?

3. What other information about this situation should you collect?

4. What nursing action(s) should you take?

References Brennan, T. A., Leape, L. L., Laird, N. M., Hebert, L., Localio, A. R., Lawthers, A. G., Hiatt, H. (2004). Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. 1991. Quality & Safety in Health Care. 13, 145-151. Saintsing, D., Gibson, L. M., & Pennington, A. W. (2011). The novice nurse and clinical decision-making: How to avoid errors. Journal of Nursing Management, 19, 354–359. Smith J. & Crawford L. (2002). Report of findings from the 2001 Employers Survey. National Council of State Boards of Nursing, Chicago, IL. Tanner, C.A. (2006) “Thinking like a nurse”; a research-based model of clinical judgment in Nursing. Journal in Nursing Education. 45(6) 204-211. Van Graan, AC, Williams, MS, Koen, MP (2016) Professional nurses’ understanding of clinical judgment: A contextual inquiry. Science Direct. Elsevier. 280-293. About the author Susan Sportsman, PhD, RN, ANEF, FAAN , is a nationally recognized speaker and consultant with over 10 years of consulting experience, providing program development and other consultation services to nursing and health professions programs throughout the United States and Canada. Previously, she served as Dean of the College of Health Sciences and Human Services at Midwestern State University in Wichita Falls, Texas. Although this is a simple situation to which a new clinical student may know the answers, these types of questions provide a framework by which the student can connect scientific knowledge to clinical judgment. As students care for more complex patients, this format can be used for more difficult questions. Sufficient evidence exists that many novice nurses are not prepared to assume the role of an RN or LPN/LVN at the time of graduation without further assistance. The NCSBN has revised the licensing exams to more fully evaluate test-takers’ clinical judgment competencies. Nursing faculty must make changes to prepare students for the NGN Exams and safe practice at the time of their graduation. Let’s commit to using every available resource and best practice to prepare students for this challenge.

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