Undergraduate nurse educators have increased the use of high-fidelity simulation (HFS) during the past 15 to 20 years (Bussard, 2015a; Grant, Moss, Epps, & Watts, 2010). Researchers have found that HFS increases critical thinking, clinical judgment, reasoning, psychomotor skills, self-confidence, communication, accountability, and interprofessionalism (Blum, Borglund, & Parcells, 2010; Bussard, 2015a; Coffman, 2012; Harder, 2010; Howard, Englert, Kameg, & Perozzi, 2011; Rizzolo, 2012). Oral debriefing following HFS scenarios is the most effective means of merging theory and practice, as well as improving clinical judgment (Cato, 2012; Lasater, 2007). Various types of debriefing exist, including oral debriefing alone, oral debriefing accompanied by use of video recordings, and reflective journaling (Bussard, 2015b; Dreifuerst, 2009; Reed, Andrews, & Ravert, 2013; Thomas-Dreifuerst & Decker, 2012). Evidence suggests that video recording, along with oral debriefing, improves communication and that skill acquisition is limited (Yoo, Yoo, & Lee, 2010). However, no evidence is available to support the use of video-recorded HFS as a teaching or learning strategy to promote self-reflection and development of clinical judgment. The purpose of this study is to reveal whether self-reflection of video-recorded HFS scenarios promotes the development of clinical judgment in prelicensure nursing students
Simulation is defined as “a pedagogy using one or more typologies to promote, improve, or validate a participant's progression from novice to expert” (Meakim et al., 2013, p. S9). HFS is the use of computerized manikins or standardized patients to provide a realistic, highly interactive learning environment, affording students the ability to develop skills, knowledge, and clinical judgments. (Hinchcliffe-Duphily, 2014; Meakim et al., 2013; Phillips, 2011; Reese, Jeffries, & Engum, 2010). A HFS manikin has the capability to produce cardiopulmonary sounds, pulses, pupillary responses, and bowel sounds; clench the jaw; become diaphoretic; hemorrhage; and talk (Bailey, Johnson-Russell, & Lupient, 2011; Bussard, 2013). The higher the capability of the manikin, the more realistic the clinical scenario will be.
The use of HFS scenarios has been shown to improve clinical judgment, self-confidence, skills acquisition, accountability, and communication skills (Anderson & Nelson, 2015; Bussard, 2015a; Dunn, Osborne, & Link, 2014; Oldenburg, Brandt, Maney, & Selig, 2012; Yuan, Williams, & Man, 2014). Clinical scenarios are created by nursing faculty to provide students with patient situations they might encounter in the clinical setting. These scenarios vary in length and complexity based on the course objectives (Meakim et al., 2013). The use of these clinical scenarios in HFS promotes a safe learning environment without harm or injury to a patient (Meakim et al., 2013).
The National League for Nursing/Jeffries Simulation Framework is used by educators to design, implement, and evaluate HFS scenarios (Jeffries, 2005). The five constructs of the framework include “educational practices, teacher, students, simulation design characteristics, and outcomes” (Groom, Henderson, & Sittner, 2014, p. 338). In 2014, the term teacher was changed to facilitator and students was changed to participants (Ravert & McAfooes, 2014). Using this framework allows nurse educators to provide students with scenarios that are theoretically based and supported by evidence-based practice.
Debriefing is a method used in which a facilitator guides students through reflective thinking exercises. Reflective thinking helps students to connect theory to practice and to understand concepts within the simulation scenario (Mariani, Cantrell, Meakim, Prieto, & Dreifuerst, 2013; Shinnick, Woo, Horwich, & Steadman, 2011; Thomas-Dreifuerst & Decker, 2012). Debriefing is most effective when done immediately following the scenario (Lasater, 2007). Oral debriefing is done face to face, in which the facilitator asks questions and guides discussion. Another option to debriefing is the use of video. The students are video recorded during the simulation scenario and then the facilitator uses snippets of data from the video to guide discussion (Chronister & Brown, 2011; Grant et al., 2010; Megel, Bailey, Schnell, Whiteaker, & Vogel, 2013; Reed et al. 2013; Yoo et al., 2010). Historically, video recording has been used in nursing education primarily as a means to help students develop psychomotor and communication skills, as well as improve patient safety measures (Sharpnack, Goliat, Baker, Rogers, & Shockey, 2013; Watts, Rush, & Wright, 2009; Winters, Hauck, Riggs, Clawson, & Collins, 2003).
Dewey, a philosopher, discussed reflective thinking in 1910 as a means of organizing one's thoughts. After one organizes his or her thoughts, the thoughts are placed into a sequence, which then directs the person's future thoughts and outcomes (Dewey, 1910/1991). Schön (1987) identified two important types of reflective thinking in nursing: reflection-in-action and reflection-on-action. Reflection-in-action is a method that nurses can use to critique themselves while caring for patients, performing interventions, or communicating. Reflection-on-action is a retrospective review of one's actions to determine necessary changes for future patient encounters (Schön, 1987).
The theoretical model that guided this study is the clinical judgment model (CJM) developed by Tanner (2006). Clinical judgment is defined as “an interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response” (Tanner, 2006, p. 204). Four concepts included in the model are noticing, interpreting, responding, and reflecting. While noticing, the nurse is identifying information that will be needed as he or she cares for the patient. The nurse may be using interview skills, observation skills, medical records, or shift reports to notice information about the patient. While interpreting, the nurse is taking data from the noticing phase and making sense of the information. As the nurse responds, he or she is putting interventions into action. Reflecting is the last component of the model, and allows the nurse to reflect-in-action or reflect-on-action. Tanner (2006) stated that reflection is the key component for nurses to develop clinical judgment.
Methodology and Design
The research question that guided this study was: What is the nature of clinical judgment development by prelicensure nursing students who self-reflected on video-recorded HFS scenarios? A qualitative, interpretive description design was used for this study. In interpretive description, the researcher uses a theoretical lens to guide the study (Thorne, 2008). The themes that emerge are evaluated related to the theoretical model, which helps the researcher interpret the data. The research question and sample are selected based on the theoretical framework.
The sample for this study included 20 prelicensure nursing students who completed their first medical–surgical nursing (MSN) course in a diploma nursing program. The MSN course is offered during the second year of the nursing program and is taken after a nursing foundations course. In the nursing foundations course, students are oriented to the HFS manikin via two basic scenarios, whereas in the MSN course, the students participated in four progressive HFS scenarios.
Although the students cared for the same patient in all four scenarios, each scenario increased in complexity throughout the semester. By caring for the same patient in all four scenarios, students were able to see disease progression and comorbidities and develop a therapeutic relationship with the patient. A description of the patient is as follows. Lillian Fox was a 50-year-old woman with a history of hypertension, chronic obstructive pulmonary disease, atrial fibrillation, diabetes mellitus, and hypercholesterolemia, who smoked cigarettes for 30 years. In the first scenario, Lillian fell and fractured her tibia. The students needed to care for Lillian by providing her with pain relief, prepare her for surgery, care for her postoperatively, manage her diabetes mellitus and hypertension, perform an assessment, administer medications, and perform a dry sterile dressing. In the second scenario, Lillian was admitted with diabetic ketoacidosis. The students were required to perform an assessment, administer medications, and provide her with diabetic education. In scenario three, Lillian had pneumonia. Students were required to perform an assessment, administer medications, and intervene during respiratory distress. Also during scenario three, Lillian developed stroke-like symptoms. The students had to conduct an appropriate neurological assessment, call for an emergency stroke team, and implement appropriate interventions. Finally, in scenario four, Lillian had a bowel obstruction, which led to a hemicolectomy. Students needed to care for a nasogastric tube, administer medications, care for a dehisced abdominal wound, and then care for her when she developed a pulmonary embolism.
Each of the scenarios were developed using the National League for Nursing/Jeffries Simulation Framework. Students worked in groups of two, with each student acting as a registered nurse. The team format provided students with the ability to communicate in an interprofessional manner. While two students were caring for Lillian, two other students were observing. After 20 minutes, the two groups of students switched roles, and the observers then cared for Lillian while the previous two students became observers. Scenarios one, two, and three were 20 minutes long for each group of two students, followed by a 20-minute oral debriefing session. The fourth scenario was 40 minutes long for each group of two students, followed by a 40-minute oral debriefing session.
Laerdal SimMan 3G® was the HFS manikin used for these scenarios. Each scenario was video recorded using Education Management Solutions, Incorporated, Simulation IQ® video software. Operation of the manikin and video equipment and facilitation of oral debriefing sessions were conducted by the same faculty members for all four scenarios. Because of the consistency in faculty members, variation was limited between all groups of students.
In the oral debriefing sessions, students were asked to reflect-on-action. The students identified information they noticed in report and on entering the patient room, which guided their nursing actions. The students were also asked to interpret patient data, disease progression, and abnormal assessment findings and reflect on the effectiveness of communication with the patient, as well as the team. Students then reflected on their responses to the patient situation. Finally, they identified what they wanted to improve on and set a goal for improvement. After oral debriefing sessions were completed, students were asked to view their video-recorded scenario within 1 week. The students viewed this video independently, without faculty facilitation.
Data Collection and Analysis
Students were retrospectively surveyed after completing the MSN course. Institutional board review was sought, but the study was deemed exempt by the Vice President of Safety and Quality because it was a retrospective study with no potential for harm or discourse to any study participant. Each student provided informed consent to participate in the study (consent was obtained after the MSN course was completed because it was a retrospective study), and they were informed that the study was voluntary. Participating in the study, or choosing not to participate in the study, had no impact on the students' course grade or curriculum progression. Inclusion criteria for this study were: students completed four progressive HFS scenarios during the MSN course, students orally debriefed after each scenario, students viewed a video recording within 1 week of completing each of the four HFS scenarios, students successfully passed the MSN course with a grade of “C” (⩾77%) or better, students signed a consent form to participate in the study, and students were older than 18 years. Demographics for the sample included four men and 16 women, ranging in age from 20 to 45 years.
A survey was developed using Tanner's CJM to form the questions. To ensure the rigor of this study, an expert nurse educator in the field of HFS and clinical judgment assessed the survey for content validity and found that the survey was valid. The nurse expert has 6 years of experience using HFS and Tanner's CJM. She has presented several times at nursing conferences and attended various international simulation conferences. The survey included nine questions (Table). The surveys were analyzed using QSR NVivo10 qualitative computer software. In addition, anonymity of surveys was maintained to ensure trustworthiness of the data analysis.
Survey Used for Data Collection
Interpretation of Findings
The nature of clinical judgment development was revealed after analyzing the surveys. Four themes emerged from the data analysis and include (a) Confidence, (b) Communication, (c) Decision Making, and (d) Change in Clinical Practice (Figure).
Nature of Clinical Judgment Development after self-reflection of video-recorded high-fidelity simulation scenarios.
Theme One: Confidence
Questions one and two of the survey pertained to the CJM phase of noticing. The students identified a lack of confidence in skills and communication while watching themselves in the first video. Student comments from the first video-recorded scenario included:
- I looked nervous on the video.
- I had a lack of communication.
- I had facial expressions I did not like.
- I was more focused on the skill then the patient.
- I looked awkward
- My time management was not good.
- I did not have good critical thinking skills.
- I was timid and unsure of myself
- My nerves got the best of me.
As the students progressed from viewing the first scenario to the fourth scenario, they identified that their confidence was improving. Student comments indicating improved confidence included:
- I was able to prime intravenous tubing after watching myself on video.
- I learned how to work in a team.
- I was able to apply my new skills into clinical [practice].
- I worked on improving myself so I was not as timid.
- I learned how to remain calm in situations.
- I was able to improve my professionalism within my team.
- I saw my peer appear confident and this helped me to realize that I wanted to appear confident to my peers and patients; so I will continue to study and gain the confidence my peer had.
- I worked on improving my facial expressions so that it would not make patients nervous.
- I began making independent decisions towards the last scenario because I gained confidence in my skills and abilities.
Theme Two: Communication
Questions three and four of the survey pertained to the CJM phase of interpreting. The students identified ineffective communication while watching the first video. Student comments included:
- I need to improve on my team work.
- I could have asked more questions to the patient to form a better patient/nurse relationship.
- I needed to improve on educating the patient and not just talking over her.
- I needed to improve my interaction with the patient.
- I need to improve my nonverbal communication.
- My communication needed improvement.
- I had too many nonverbal facial tics and did not talk loud enough.
- I lacked communication with my peers.
After viewing the fourth scenario, students identified improved communication. Student comments included:
- I focused on improving nonverbal communication in clinical situations after watching my video simulation.
- Communication improves patient outcomes.
- My communication became more comfortable as time went on.
- I made sure to include the patient in their care and explained everything.
- I began asking my patients more questions and learned a great deal of valuable information related to patient care and history.
- Communication improved with my peers as the scenarios progressed.
- I worked on improving my nonverbal communication.
- I now make sure to fully communicate with my patient.
- It's important to let [the patients] know what you are doing and why you are doing it.
- I communicated clearly with my partner.
- I provided patient education.
- I had professional communication throughout the scenario with both my peers and the patient.
- I tried to think clearly and convey that to my peer.
Theme Three: Decision Making
Questions five, six, seven, and eight on the survey pertained to the CJM phase of responding. The students identified that decision making guided all patient care. Student comments included:
- I did not administer medications properly.
- I need to improve on sterile dressings.
- I noticed that I was not organized or efficient in my patient care.
- I need to take my time when performing skills.
- I need to be more careful when making decisions; it is easy to make a mistake when not 100% focused.
- I was hesitant to make decisions.
- I needed to prioritize my interventions better.
- I need to be more systematic with my thinking.
- I was slow to respond because of a lack of experience.
In video four, students felt confident while making decisions for patient care, used cues to help guide decisions, and looked at all aspects of patient care. Student comments included:
- I improved my skills by reviewing them before simulation.
- I could see improvement in skills, decision making, and confidence from the first to the fourth video.
- Seeing myself improve on decision making from the first video to the fourth video built self-confidence for future clinical and skills [laboratories].
- My clinical judgment was strengthened.
- I noticed subtle changes in my patient that helped guide my care.
- I feel that I have become quicker in making decisions that are sound decisions.
- I am more specific in my interventions.
- I was not as rushed and put more thought into my decisions and interventions.
- I was not as hesitant to make decisions and was more confident in myself.
- I think more clearly before making decisions; I evaluate the pros and cons first.
- I felt more confident to make decisions based on my patients best interest because I saw myself being confident in the videos.
- I do not second guess myself anymore or overthink my decisions.
- I had reassurance that my decisions were good decisions by watching the videos.
Theme Four: Change in Clinical Practice
Question nine on the survey pertained to the CJM phase of reflecting. The students identified that they could see improvement in skills, decision making, confidence, and overall performance from the first to the fourth video. Student comments included:
- Watching the videos provided a safe and confidential learning environment where I could think through the scenario, pause the video, and figure out how to improve in future patient encounters.
- The videos were more beneficial then oral debriefing; I was able to see negatives and positives about myself and make improvements in clinical and skills [laboratory].
- Being able to see myself on the video really put the scenario into perspective and this played a huge role in my clinical judgment development and future patient care.
- I will incorporate looking at the patient as a whole.
- I was able to learn from my mistakes so that I don't do those same mistakes when taking care of patients in the future.
- I learned that not every situation is the same and every patient is not the same, so I need to go with my gut and have faith in myself so I can think like a nurse quickly.
- I was able to see my advantages and disadvantages and what I needed to work on for future patient situations.
- I can recognize proper prioritization and implement that in patient care now.
- I know that it is okay to bounce ideas off of my peers because we don't know everything, so it is okay to ask questions when I don't have the answer.
- I was able to rework my next simulation or clinical interaction after watching the videos.
As HFS becomes increasingly popular in health care education, faculty should look at best practices for using HFS equipment as a teaching or learning strategy. Students identified that viewing the video recordings independently after participating in HFS scenarios was beneficial and an effective learning strategy. Student responses to the survey revealed the nature of clinical judgment development in all four phases of the CJM (noticing, interpreting, responding, and reflecting). A student's ability to reflect on his or her actions, decision making, psychomotor skills, and communication in a video were identified in this study. A salient component of this study suggests that a student who views himself or herself on video will reflect-on-action and therefore make improvements to his or her practice for future patient encounters, thus indicating development of clinical judgment. All four themes are essential for a student to develop clinical judgment. Without Confidence, Communication, Decision Making, or a Change in Clinical Practice, clinical judgment may not develop.
Implications, Recommendations for Further Studies, and Limitations
As more schools of nursing search to implement various teaching–learning strategies to develop clinical judgment, video recording of HFS scenarios may be an effective option. This study provides colleges and schools of nursing justification for purchasing audio/visual equipment for simulation. It is recommended that quantitative research be done to identify whether students have a change in knowledge, attitude, or skills after watching the video-recorded simulation scenarios. In addition, it would be beneficial to identify when the video should be watched, whether it be immediately following the scenario, 48 hours later, or longer.
Several limitations exist in this study. The study was conducted in one school of nursing with one medical–surgical nursing course, and there was a small sample size of 20. Another limitation of the study is that only one expert nurse ensured content validity of the survey.
HFS has become a widely used educational tool in undergraduate nursing programs. Oral debriefing has become the hall-mark component of HFS scenarios for the development of clinical judgment. Recently, video-recorded segments of the scenario have been used to supplement the oral debriefing sessions. This study looked at using the video recordings as an independent activity to self-reflect on the HFS scenario. The results of this study indicate that self-reflecting on video-recorded HFS can be effective for prelicensure nursing students to develop clinical judgment. Students who are able to improve confidence, communication, and decision making after viewing recorded HFS scenarios can therefore improve future clinical nursing practice.
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Survey Used for Data Collection
When you reviewed your simulation videos, what types of things did you notice about yourself that you wanted to change? What did you want to do the same?
When you reviewed your simulation videos, what did you notice from your partner that was a negative or positive attribute? Did this guide your nursing decisions as you continued your education and in what way?
How did you interpret your communication with the patient and peers after viewing the simulation scenarios?
What type of changes did you incorporate into your practice after you made these interpretations about your communication?
How did you interpret your skill performance in tasks such as medication administration, sterile dressing change, and assessment after viewing the simulation scenarios?
What type of changes did you incorporate into your practice after you made these interpretations about your skill performance?
After you viewed the simulation videos, how was your response to making decisions for your patient?
How has your decision responses in clinical and laboratory experiences changed since viewing these simulation videos?
Reflecting on these simulation videos, what is your opinion as to how they helped you develop clinical judgment skills? Clinical judgment is the ability to think like a nurse, notice information, interpret the cues, respond to the patient, and then reflect on the situation (Tanner, 2006).