Journal of Nursing Education

Major Article 

A Rubric to Assess Students' Clinical Reasoning When Encountering Virtual Patients

Carina Georg, MSN, RN; Klas Karlgren, PhD; Johanna Ulfvarson, PhD, RN; Maria Jirwe, PhD, RN; Elisabet Welin, PhD, RN

Abstract

Background:

Training with virtual patients has been proposed as a suitable learning activity to improve clinical reasoning skills for nursing students. However, published instruments with the capacity to assess students' reasoning process in the encounter with virtual patients are lacking.

Method:

Deductive and abductive analyses were used to adapt the Lasater Clinical Judgment Rubric (LCJR) to assess nursing students' clinical reasoning skills in the encounter with virtual patients. The new rubric's ability to capture nursing students' clinical reasoning processes was tested using deductive analysis and statistical analysis.

Results:

A grading rubric for virtual patients, the vpLCJR, was developed. Cronbach's alpha showed .892, indicating good internal consistency.

Conclusion:

The rubric vpLCJR, which deconstructs aspects of clinical reasoning for both students and faculty members, can be used to clarify expectations, assess students' clinical reasoning process, and provide feedback for learning when nursing students encounter virtual patients. [J Nurs Educ. 2018;57(7):408–415.]

Abstract

Background:

Training with virtual patients has been proposed as a suitable learning activity to improve clinical reasoning skills for nursing students. However, published instruments with the capacity to assess students' reasoning process in the encounter with virtual patients are lacking.

Method:

Deductive and abductive analyses were used to adapt the Lasater Clinical Judgment Rubric (LCJR) to assess nursing students' clinical reasoning skills in the encounter with virtual patients. The new rubric's ability to capture nursing students' clinical reasoning processes was tested using deductive analysis and statistical analysis.

Results:

A grading rubric for virtual patients, the vpLCJR, was developed. Cronbach's alpha showed .892, indicating good internal consistency.

Conclusion:

The rubric vpLCJR, which deconstructs aspects of clinical reasoning for both students and faculty members, can be used to clarify expectations, assess students' clinical reasoning process, and provide feedback for learning when nursing students encounter virtual patients. [J Nurs Educ. 2018;57(7):408–415.]

Newly graduated nurses are expected to be prepared and to possess the knowledge and skills required to provide safe, evidence-based nursing practice in varied settings and complex situations (Benner, Tanner, & Chesla, 2009). One key aspect of clinical competency is clinical reasoning (Audétat, Laurin, Dory, Charlin, & Nendaz, 2017); therefore, the development of nursing students' clinical reasoning skills is a major goal of nursing education (Jessee & Tanner, 2016).

The terms clinical reasoning, clinical judgment, and clinical decision making are often used interchangeably (Banning, 2008; Benner, Sutphen, Leonard, & Day, 2010; Norman, 2005; Simmons, 2010). In this article, the term clinical reasoning is used to describe the cognitive processes and strategies underlying how nurses collect cues, process this information, come to an understanding of the patients' stories and situations, plan and implement interventions, evaluate outcomes, and reflect and learn from these processes (Levett-Jones et al., 2010).

The use of virtual patients has been acknowledged as well-suited for fostering and assessing health care students' development of clinical reasoning (Hege, Kononowicz, Tolks, Edelbring, & Kuehlmeyer, 2016; Cook & Triola, 2009). However, instruments that have the capacity to objectively assess the learners' clinical reasoning processes during virtual patient simulations are lacking. Most current methods to assess, give feedback on, and score students' clinical reasoning abilities in relation to virtual patients are outcome oriented and do not account for the nonlinear nature of the clinical reasoning process (Hege, Kononowicz, & Adler, 2017).

One way of assisting students and educators in objectively assessing students' performance and communicating different aspects and levels of clinical reasoning is the use of rubrics (Shipman, Roa, Hooten, & Wang, 2012). In its most basic definition, a rubric is a measurement instrument that articulates the expectations for an assignment or a task by listing performance criteria and describing levels of performance quality. Essential components of a rubric include concise performance criteria and rating scales, as well as descriptions of the expected performance at each level (Davis & Kimble, 2011). The Lasater Clinical Judgment Rubric (LCJR) is a rubric that has been used by educators to assess nursing students' clinical reasoning and judgment skills in encounters with high-fidelity simulations using human-like mannikins (Adamson, Gubrud, Sideras, & Lasater, 2012; Kardong-Edgren, Adamson, & Fitzgerald, 2010; Lasater, 2007, 2011). The LCJR is based on the conceptual framework of Tanner's clinical judgment model (Tanner, 2006). In the LCJR, Lasater builds on Tanner's (2006) model to assess the cognitive, affective, and psychomotor aspects of clinical reasoning (Kardong-Edgren et al., 2010; Miraglia & Asselin, 2015). The LCJR has been validated and used for educational and research purposes in several studies (Adamson, Gubrud, Sideras, & Lasater, 2012; Ashcraft et al., 2013; Jensen, 2013) and has been modified for different contexts (Ashcraft et al., 2013; Kim, Kim, Kang, Oh, & Lee, 2016; Kristiansen, Häggström, Hallin, Andersson, & Bäckström, 2015; Miraglia & Asselin, 2015; Shin, Shim, Lee, & Quinn, 2014) but always in relation to high-fidelity simulations using human-like mannikins.

Although the use of virtual patients may be well-suited for assessing the development of clinical reasoning, published instruments with the capacity to support the acquisition of clinical reasoning skills and to assess the different steps in the nursing students' reasoning process are lacking. The LCJR may have potential for use in the context of virtual patients as well, but given that different simulation modalities address different learning objectives and educational outcomes (Cant & Cooper, 2017), modifications may be needed to address the characteristics of clinical reasoning that are typical for encounters with virtual patients.

Therefore, the aims of this study were to (a) develop an assessment rubric guided by the LCJR to assess nursing students' clinical reasoning processes when encountering virtual patients, and (b) to test the new assessment rubric's abilities to capture the nursing students' clinical reasoning processes as they encounter virtual patients.

Method

Study Design

This study had a two-phase design. In phase 1, the LCJR was adapted to assess nursing students' clinical reasoning skills in encounters with semi-linear virtual patients, and in phase 2 the newly developed rubric's abilities to capture nursing students' clinical reasoning processes during virtual patient simulations were tested.

Setting and Participants

The study was conducted at a medical university in Sweden offering an undergraduate nursing program. In Sweden, nursing education takes the form of a 3-year postsecondary training course leading to a of Bachelor of Science in Nursing degree. A convenience sample of second-year nursing students (N = 130) participating in a clinical course was invited to take part in the study; five declined to participate, for a total of 125. In phase one (adaptation of the rubric) students (n = 97) interacted with virtual patient cases developed in the virtual patient case system (virtual interactive case system; VIC) (Toronto General Hospital, 2017). In phase 2 (test of the new rubric), students (n = 28) interacted with virtual patient cases developed in the Web-SP system (Zary, Johnson, Boberg, & Fors, 2006).

Both the VIC and Web-SP cases are exploratory semilinear in design (an instructional design about how the learners navigate through the case) (Huwendiek et al., 2009). The cases begin with the presenting complaint. The students' task was to assess the patient in order to frame the situation based on the narrative of the patient. The assessment was performed by taking a patient history, conducting a physical examination, and reviewing diagnostic test results and health records from other professionals. The patient assessment was conducted by selecting items from lists of questions or actions in different categories (history, physical examination, diagnostic test) with a tab for each category and submenus under each tab to group items within the tab.

Data Collection

One of the online learning activities in the course was working with virtual patients, based on the virtual patient nursing design model (vpNDM) (Georg & Zary, 2014). The vpNDM is based on the outcome present state model (OPT model), which provides a structure for iterative clinical reasoning and emphasizes reflection, outcome specification, and testing, given the story of the patient (Kautz, Kuiper, Pesut, Knight-Brown, & Daneker, 2005; Pesut & Herman, 1998, 1999). The complexity of the cases was based on the intended learning outcome for the course. The virtual patient case used in this study illustrated an older man with type 2 diabetes who was admitted to the ward with heart failure, hyperglycemia, and an acute diabetic foot. The nursing diagnosis in this virtual patient case was related to excess fluid volume, impaired gas exchange, impaired urinary elimination, impaired skin integrity, risk for unstable blood glucose level, readiness for enhanced knowledge, and readiness for enhanced self-management (NANDA International, 2014).

During the interaction with the virtual patient, the students answered questions (n = 15) that were based on the OPT model. The questions were related to the narrative of the patient, the use of standardized nursing terminology, written health records, and plans for the care of the patient, as well as reflection on action and on the students' clinical learning (Georg & Zary, 2014). The students answered in the form of a short summary statement capturing important case elements that comprised the data for this study.

Phase One: Development of the Rubric

To investigate whether the aspects of clinical reasoning included in the LCJR were applicable for assessing encounters with virtual patients and to identify aspects needing modification, a qualitative deductive content analysis was used in line with Elo's and Kyngäs's (2008) description. As a first step of the analysis, the authors read and reviewed all students' (n = 97) texts several times to become familiar with the data. To test which aspects of the LCJR were applicable to encounters with virtual patients, the students' texts were coded using the phases, dimensions, and development descriptors of the LCJR as a lens and coding scheme. To adapt items in the original LCJR that did not cover clinical reasoning aspects expressed in virtual patient simulation, an abductive analysis was conducted according to Timmermans's and Tavory's description (Tavory & Timmermans, 2014; Timmermans & Tavory, 2012). An iterative process of open/axial coding and alternative casing was used to modify the items to frame the clinical reasoning aspects that emerged in virtual patient simulation. To discover patterns and relationships within the findings, the team tested out alternative codes and dimensions for the rubric, attempting to find and test as many ways as possible to understand the data. Inconsistencies were resolved by consensus. This process of theoretical coding and iterative dialog continued until saturation was reached. Final decisions about the dimensions, phases, and saturation were made through discussion. During the analysis, a complementary process of defamiliarization and revisiting was used that involved analyzing the data word by word, line by line, and paragraph by paragraph to form as many links and hypotheses as possible, in light of theoretically positioned knowledge. Careful memorandum writing was conducted throughout the entire process. The analytical procedure was an iterative process of going back to the data, rubric, and analytical memos to clarify and refine the rubric.

Phase Two: Testing the Rubric

Face Validity of the Adapted Rubric. To check the face validity of the assessment instrument, including risks for misinterpretation of the wordings, a convenience sample of researchers working in the fields of education (n = 7), nursing (n = 4), and clinical nursing (n = 4) was recruited.

Test of the Adapted Rubric by Scoring Students' Performance. To test the usability and utility of the new rubric, a deductive content analysis was conducted (Elo & Kyngäs, 2008). Texts that nursing students (n = 28) (93% [n = 26] women, mean age = 31 years) produced while interacting with the virtual patient developed in the Web-SP environment served as data for this analysis. The analysis was performed in three steps. First, each student's text was read through several times to gain an understanding of the data. In the second step, two of the authors (C.G., E.W.) independently analyzed each student's text using the dimensions and development descriptors of the new rubric (as a categorization matrix and as predefined coding categories). The students were ranked into each dimension based on the actions taken and answers given (the short summary statements) to the questions during the virtual patient encounters. In the third step, when a good sense of the material's content had been reached, the two authors (C.G., E.W.) compared and discussed each other's coding until consensus was reached.

Statistical Analysis. After the deductive content analysis was finalized and each student's (n = 28) texts had been categorized (according to the dimensions and development descriptors [n = 44] of the new rubric), the levels of each development descriptor were converted, based on Lasater's (2007) description, to an ordinal scale ranging from 1 to 4, where level 1 represented beginning, level 2 represented developing, level 3 represented accomplished, and level 4 represented exemplary. The students' clinical performances were calculated and the results were quantified (Krippendorff, 2013). Statistical analyses of the results were conducted using SPSS® version 22 software. A descriptive statistical analysis was performed, and percentages were calculated. Cronbach's alpha was calculated to provide an overall reliability coefficient for the set of items in the rubric.

Ethical Considerations

The simulations took place as required course activities, and the participants were informed both orally and in writing about the study's purpose, as well as notified that participation in the research part was voluntary. The copyright holder of the LCJR, Dr. Lasater, granted permission to modify the rubric in order to make it suitable for use with virtual patients. The study was conducted according to the declaration of Helsinki and was approved by the Regional Ethical Review Board in Stockholm.

Results

Phase One: Development of the Rubric, vpLCJR

A new rubric, the virtual patient LCJR (vpLCJR), was developed. The LCJR provided the basis for the vpLCJR, and the new rubric maintained the same structure as the original LCJR. Both rubrics consisted of specific dimensions within Tanner's (2006) four phases of clinical reasoning and clinical judgment: noticing, interpreting, responding, and reflecting. Each phase is further described in two or three dimensions that elucidate what is meant by the phase (a total of 11 dimensions). The dimensions are also delineated with development descriptors typical for best and worst performance. Best and worst performance indicators were broken down into for four distinct developmental levels: beginning, developing, accomplished, and exemplary. As in the original LCJR, a 4-item Likert scale ranging from 1 (beginning) to 4 (exemplary) was included in the rubric for rating purposes (Lasater, 2007).

The phase Noticing, which consisted of the three dimensions of focused observation, recognition deviation from expected patterns, and information seeking, addressed a high-degree clinical reasoning aspect that is enhanced in a virtual patient simulation. Therefore, there was no need to adapt this phase.

The dimensions and development descriptors in the phase Interpreting in the LCJR were in most aspects well aligned with interpreting aspects raised in virtual patient simulation. However, aspects that broadened the meaning of making sense of data by addressing the way the students framed the patient's story were added to the rubric (Table 1).

Changes in the Interpreting Domain

Table 1:

Changes in the Interpreting Domain

The Responding phase was remodeled with regard to both its dimension and development descriptions. In the LCJR, both dimensions and development descriptors to a large extent address affective and psychomotor aspects that were not applicable for assessment in a simulation with virtual patients. However, simulations with virtual patients are well suited for students to demonstrate their ability to plan for patient care and to communicate such plans by establishing a nursing health record for the patient. Therefore, this element was added to the vpLCJR (Table 2).

Changes in the Responding DomainChanges in the Responding Domain

Table 2:

Changes in the Responding Domain

The Reflecting phase included two dimensions: self-analysis and commitment to improvement. Given that the items and descriptions of the LCJR provided good possibilities to identify students' abilities to reflect on action and clinical learning also in relation to virtual patient simulation activity, there was no need to adapt these.

The final rubric vpLCJR is shown in Table A (available in the online version of this article).

The Virtual Patient Version of the Lasater Clinical Judgment Rubric (vpLCJR)The Virtual Patient Version of the Lasater Clinical Judgment Rubric (vpLCJR)The Virtual Patient Version of the Lasater Clinical Judgment Rubric (vpLCJR)

Table A:

The Virtual Patient Version of the Lasater Clinical Judgment Rubric (vpLCJR)

Phase Two: Test of the vpLCJR's Abilities to Capture Aspects of Nursing Students' Clinical Reasoning Processes

Face Validity Test. Experts in the field of medical education and nursing found the use of the items in the vpLCJR relevant to capture nursing students' clinical reasoning process in relation to virtual patient simulation. They recommended a minor modification of the wording to improve understanding. This modification was added to the final version of the vpLCJR.

Usability Test of the Rubric and Statistical Analysis. To test the construct validity and the rubric's ability to capture nursing students' clinical reasoning process in their encounters with virtual patients, a deductive content analysis was conducted. The response process showed that the students' responses were distributed over all dimensions of the instrument. The mean clinical reasoning skill score using the vpLCJR was 29.75 points (SD = 6.2), with a median of 31, and the observed range was 15 to 44.

As a measure of reliability, Cronbach's alpha was used to analyze the assessment instrument, and this showed .892, indicating consistent reliability. The subdomain with the highest Cronbach's alpha was Reflecting (α = .904), followed by Noticing (α = .9), Interpreting (α = .85), and Responding (α = .85). The skewness was (−1, 0, +1).

Discussion

Virtual patients have been acknowledged as being well-suited and providing a safe environment for fostering and assessing health care students' development of their clinical reasoning (Cook & Triola, 2009). The use of virtual patients to foster and evaluate nursing students' clinical reasoning abilities is increasing. However, there is a lack of instruments that can be used for assessing and supporting the acquisition of clinical reasoning skills and that also have the capacity to assess the different steps of nursing students reasoning process during virtual patients' simulations.

In this study, we developed a rubric, the vpLCJR, that was intended to elucidate and assess aspects of nursing students' clinical reasoning processes in their encounters with virtual patients. The contribution of this study is twofold:

  • It describes a rubric, the vpLCJR, with a theoretical foundation in Tanner's (2006) clinical judgment model, which has the capacity to the evaluate strengths and flaws in nursing students' clinical reasoning when encountering virtual patients.
  • It provides a description of the development process using abductive analysis that may serve as a guide for others who are modifying rubrics.

We also performed a first test of the vpLCJR's ability to capture aspects of the nursing students' clinical reasoning processes during encounters with virtual patients. To the best of our knowledge, this is the first attempt to elucidate nursing students' reasoning processes when encountering virtual patients.

The vpLCJR is based on the LCJR, which applies Tanner's (2006) evidence-based model of clinical judgment. However, the LCJR was developed to be used with simulations using human-like mannikins (Lasater, 2007). Due to the fact that virtual patient and mannikin simulations address different learning objectives and facilitate different learning experiences (Cant & Cooper, 2017), there was a need to review and adapt the different items' abilities to capture clinical reasoning aspects in the virtual patient setting.

The items in the Noticing and Reflecting phases were found to capture clinical reasoning aspects that appeared in encounters with virtual patients and modifications were therefore not necessary.

In the Interpreting phase, aspects that addressed how the learners capture and frame the story of the patient were added. This is because virtual patients provide the students with additional opportunities to expose their ability's to capture and interpret the narrative of the patient. The ability to frame and capture the story of the patient can be considered a marker for clinical reasoning because it requires that the students synthesize and prioritize information from the patient (Benner et al., 2009).

The items in the Responding phase, which represents the outcome of the clinical reasoning process, were completely remade on both dimension and description levels. In the original LCJR, the Responding phase focused on psychomotor and affective aspects, abilities, and skills that could be appropriate evaluated in mannikin simulation but were not applicable to assess in a simulation with virtual patients. Instead, virtual patient simulations have an inherent capacity in allowing students to demonstrate their ability to plan patient care and to communicate this plan by establishing a nursing health record for the patient. The ability to write a coherent, cogent, accurate, and complete summary statement or health record is recognized as a marker of clinical reasoning (Heist, Kishida, Deshpande, Hamaguchi, & Kobayashi, 2016; Peddle, Bearman, & Nesel, 2016; Smith et al., 2016). In the vpLCJR, the items in the Responding phase outline the learners' abilities to document relevant aspects of the patient's care from a nursing point of view in the patient's health records. This also outlines students' abilities to determine an appropriate course of action by planning relevant nursing interventions related to the patient's needs. The items also provide an opportunity to assess students' abilities in using different types of classification systems for the nursing care data (e.g., a classification system for nursing diagnoses, nursing interventions, and nursing outcomes).

The current study used abductive analysis to develop an assessment rubric guided by the LCJR. The tracking back and forth between the rubric and the data, as well as theorizing on data, allowed for inferences to emerge during the process of analysis, a movement that was facilitated by applying alternative constructions. Thus, the method provided a navigation map for constructing empirically based theorizations that revealed the meaning of Noticing, Interpreting, Responding, and Reflecting in the light of virtual patient simulation.

A goal of the study was to test the vpLCJR's ability to capture aspects of the nursing students' clinical reasoning process as they encountered virtual patients. The results showed that the students' scores were distributed over all dimensions of the instrument, which indicates that the different dimensions and development descriptors of the vpLCJR have the ability to capture different aspects of clinical reasoning and have the potential for use in evaluating nursing students' clinical reasoning performances during their encounters with virtual patients. The Cronbach's alpha in this study indicated that the new assessment rubric had acceptable reliability, but further analysis of the psychometric properties, reliability, and validity of the rubric is needed.

Limitations

The limitations of this study include the nature and the small size of the sample. However, this study is qualitative and aimed at developing and test a rubric for assessing clinical reasoning in relation to virtual patient simulation. Another limitation is that the participants were limited to a convenience sample from a single site and a single student-level group, which limits the generalizability of the findings to other contexts. The interrater reliability of faculty members using the vpLCJR was not assessed for this study. Nevertheless, the faculty members involved in the evaluation discussed the scoring and reached a consensus. Furthermore, the vpLCJR was created and tested for use with exploratory semilinear virtual patients (Huwendiek et al., 2009). Still, the vpLCJR may have potential to be used with branched virtual patients and further research is therefore recommended to investigate how the vpLCJR captures clinical reasoning processes in branched virtual patient cases.

Conclusion

The vpLCJR describes aspects of clinical reasoning for both students and faculty members. The rubric deconstructs different aspects of the clinical reasoning process, and thus the vpLCJR provides a defined set of performance criteria and expectations of what the students should achieve. Thereby, the rubric can serve as a model for students' development in thinking like a nurse and helps students engage in self-reflection about their strengths, weaknesses, and progression of their clinical reasoning process. For faculty members, the vpLCJR provides a structure for making structurally observations about nursing students' clinical reasoning process. In order to support the student's development of clinical reasoning skills, faculty members can also use the vpLCJR to assess students' clinical reasoning skills and provide feedback to students. At present, we recommend the vpLCJR should be incorporated in more formative assessment of nursing students' clinical reasoning process when encountering virtual patients as a means to promote higher order learning with a focus on clarifying expectations and providing feedback for learning.

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Changes in the Interpreting Domain

Prioritizing Data

LCJRvpLCJR


ExemplaryAccomplishedDevelopingBeginningExemplaryAccomplishedDevelopingBeginning
Focuses on the most relevant and important data useful for explaining the client's condition.Generally focuses on the most important data and seeks further relevant information, but also may try to attend to less pertinent data.Makes an effort to prioritize data and focus on the most important, but also attends to less relevant or useful data.Has difficulty focusing and appears not to know which data are most important to the diagnosis; attempts to attend to all available data.No changesNo changesNo changesNo changes

Making Sense of Data

LCJRvpLCJR


ExemplaryAccomplishedDevelopingBeginningExemplaryAccomplishedDevelopingBeginning

Even when facing complex, conflicting, or confusing data, is able to (a) note and make sense of patterns in the patient's data, (b) compare these with known patterns (from the nursing knowledge base, research, personal experience, and intuition), and (c) develop plans for intervention that can be justified in terms of their likelihood of success.In most situations, interprets the patient's data patterns and compares with known patterns to develop an intervention plan and accompanying rationale; the exception are rare or complicated cases where it is appropriate to seek the guidance of a specialist or more experienced nurse.In simple, common, or familiar situations, is able to compare the patient's data patterns with those known and to develop or explain intervention plans; has difficulty, however, with even moderately difficult data or situations that are within the exceptions for students, appropriately requires advice or assistance.Even in simple, common, or familiar situations, has difficulty interpreting or making sense of data; has trouble distinguishing among competing explanations and appropriate interventions, requiring assistance both in diagnosing the problem and in developing intervention.Added: Identifies and puts words into a balanced picture of the patient's unique story and care needs. Distinguishes between central issues or problems and peripheral issues and problems.Added: Frames and captures the patient's story in his or her context. Frames a relevant picture of the patient's situation and care needs.Added: Has some difficulty in framing and capturing the patient's story and care needs.Added: Has difficulties in framing, capturing, and creating a meaning out of the patient's story and care needs.

Changes in the Responding Domain

LCJRvpLCJR


ExemplaryAccomplishedDevelopingBeginningExemplaryAccomplishedDevelopingBeginning
Calm confident mannerDocumentation; initial patient status and nursing history
Assumes responsibility; delegates team assignments; assesses patients and reassures them and their families.Generally displays leadership and confidence and is able to control or calm most situations; may show stress in particularly difficult or complex situations.Is tentative in the leader role; reassures patients and families in routine and relatively simple situations, but becomes stressed and disorganized easily.Except in simple and routine situations, is stressed and disorganized, lacks control, makes patients and families anxious or less able to cooperate.Integrates clear record keeping regarding the patient's health history and initial status. Clear description of the patient's status. Uses only relevant data/data analysis. Uses standardized nursing terminology and medical record language.Clear record keeping regarding the patient's health history and initial status. Clear description of the patient's status. May lack some aspects. Repeats certain information. Well written diction. Uses relevant nursing terminology.Makes an effort to describe the patient's health history and initial patient status; however, lacks some aspects. Parts of the description are superficial or too general/simplistic analysis of the data. Applies relevant nursing terminology to some extent.Lacks key elements of the patient's history and initial status. Has difficulties in creating an understanding of the patient's initial status. Lack of accuracy in language use, does not use relevant nursing terminology.
Clear communicationIdentifying nursing diagnoses and desired patient outcomes
Communicates effectively; explains interventions; calms and reassures patients and families; directs and involves team members, explaining and giving directions; checks for understanding.Generally communicates well; explains carefully to patients; gives clear directions to team; could be more effective in establishing rapport.Shows some communication ability (e.g., giving directions); communication with patients, families, and team members is only partly successful; displays caring but not competence.Has difficulty communicating; explanations are confusing; directions are unclear or contradictory; patients and families are made confused or anxious and are not reassured.Relevant and clear rationales for the nursing diagnosis and nursing outcome. Formulated in a relevant way using standardized nursing terminology/classification systems.Coherence between nursing care needs, nursing diagnosis, and nursing outcome. However not completely formulated with a standardized nursing terminology/classification system.Describes partially relevant nursing diagnoses and nursing outcomes. However, has difficulties phrasing the text (so that the need/problem becomes clear or nursing outcomes can be evaluated).Has difficulties describing the patient's nursing care needs, nursing diagnosis, and nursing outcomes. Does not use nursing terminology.
Well-planned intervention/flexibilityWell-planned intervention
Interventions are tailored for the individual patient; monitors patient progress closely and is able to adjust treatment as indicated by patient response.Develops interventions on the basis of relevant patient data; monitors progress regularly but does not expect to have to change treatments.Develops interventions on the basis of the most obvious data; monitors progress but is unable to make adjustments as indicated by the patient's response.Focuses on developing a single intervention, addressing a likely solution, but it may be vague, confusing, and/or incomplete; some monitoring may occur.Prescribes relevant evidence-based nursing interventions.Prescribes mostly relevant nursing interventions.Some difficulties identifying relevant nursing interventions.Does not prescribe relevant nursing interventions. Prescribes interventions from the perspective of other health professionals.
Being skillfulBeing skillful
Shows mastery of necessary nursing skills.Displays proficiency in the use of most nursing skills; could improve speed or accuracy.Is hesitant or ineffective in using nursing skills.Is unable to select and/or perform nursing skills.Clear coherence between the different steps in the nursing process. Well-developed holistic approach.Clear coherence between the different steps in the nursing process. It is possible to understand prescriptions and evaluate the efficacy of prescriptions and changes in status.Little coherence between the different steps in the nursing process. Difficult to follow the nursing care plan and understand how the patient should be treated and how outcome will be measured.No coherence between the different steps in the nursing process. Superficial description of the nursing care plan. Very difficult to follow the nursing care plan.

The Virtual Patient Version of the Lasater Clinical Judgment Rubric (vpLCJR)

Dimensions4 Exemplary3 Accomplished2 Developing1 Beginning
Effective noticing involves:
Focused observationsFocused observation appropriately; regularly observes and monitors a wide variety of objective and subjective data to uncover any useful information.Regularly observes and monitors a variety of data, including both subjective and objective; most useful information is noticed, may miss the most subtle signs.Attempts to monitor a variety of subjective an objective data, but is overwhelmed by the array of data; focuses on the most obvious data, missing some important information.Confused by the clinical situation and the amount/type of data; observation is not organized and important data are missed, and/or assessment errors are made.
Recognizing deviations from expected patternsRecognizes subtle patterns and deviations from expected patterns in data and uses these to guide the assessment.Recognizes most obvious patterns and deviations in data and uses these to continually assess.Identifies obvious patterns and deviations, missing some important information; unsure how to continue the assessment.Focuses on one thing at a time and misses most patterns/deviations from expectations; misses opportunities to refine the assessment.
Information seekingAssertively seeks information to plan intervention: carefully collects useful subjective data from observing the patient and from interacting with the patient and family.Actively seeks subjective information about the patient's situation from the patient and family to support planning interventions; occasionally does not pursue important leads.Makes limited efforts to seek additional information form the patient/family; often seems not to know what information to seed and/or pursues unrelated information.Is ineffective in seeking information; relies mostly on objective data; has difficulty interacting with the patient and family and fails to collect important subjective data.
Effective interpreting involves:
Prioritizing dataFocuses on the most relevant and important data useful for explaining the patient's condition.Generally focuses on the most important data and seeks further relevant information, but also may try to attend to less pertinent data.Makes an effort of prioritize data and focus on the most important, but also attends to less relevant/useful data.Has difficulty focusing and appears not to know which data are most important to the diagnosis; attempts to attend to all available data.
Making sense of dataEven when facing complex, conflicting, or confusing data, is able to (a) note and make sense of patterns in the patient's data, (b) compare these with known patterns (from the nursing knowledge base, research, personal experience, and intuition), and (c) develop plans for intervention that can be justified in terms of their likelihood of success. Identifies and puts words into a balanced picture of the patient's unique story and care needs. Distinguishes between central issues or problems and peripheral issues and problems.In most situations, interprets the patient's data patterns and compares with known patterns to develop an intervention plan and accompanying rationale; the exceptions are rare or complicated cases where it is appropriate to seek the guidance of a specialist or more experienced nurse. Frames and captures the patient's story in his/her context. Frames a relevant picture of the patient's situation and care needs.In simple or common or familiar situations, is able to compare the patient's data patterns with those known and to develop or explain intervention plans; has difficulty, however, with even moderately difficult data or situations that are within the exceptions for students, inappropriately requires advice or assistance. Has some difficulty in framing and capturing the patient's story and care needs.Even in simple, common, or familiar situations, has difficulty interpreting or making sense of data; has trouble distinguishing among competing explanations and appropriate interventions, requiring assistance both in diagnosing the problem and in developing intervention. Has difficulties in framing, capturing, and creating a meaning out of the patient's story and care needs.
Effective responding involves:
Documentation; initial patient status and nursing historyIntegrates clear record keeping regarding the patient's health history and initial status. Clear description of the patient's status. Uses only relevant data/data analysis. Uses standardized nursing terminology and medical record language.Clear record keeping regarding the patient's health history and initial status. Clear description of the patient's status. May lack some aspect. Repeats certain information. Well written diction. Uses relevant nursing terminology.Makes an effort to describe the patient's health history and initial patient status; however, lack some aspects. Parts of the description are superficial or too general/simplistic analysis of the data. Applies relevant nursing terminology to some extent.Lacks key elements of the patient's history and initial status. Has difficulties in creating an understanding of the patient's initial status. Lack of accuracy in language use, does not use relevant nursing terminology.
Identifying nursing diagnoses and desired patient outcomesRelevant and clear rationales for the nursing diagnosis and nursing outcome. Formulated in a relevant way using standardized nursing terminology/classification systemsCoherence between nursing care needs, nursing diagnosis, and nursing outcome. However, not completely formulated with a standardized nursing terminology/classification system.Describes partially relevant nursing diagnoses and nursing outcomes. However, has difficulties phrasing the text (so that the need/problem becomes clear or nursing outcomes can be evaluated).Has difficulties describing the patients nursing care needs, nursing diagnosis, and nursing outcomes. Does not use nursing terminology.
Well-planned interventionPrescribes relevant evidence-based nursing interventions.Prescribes mostly relevant nursing interventions.Some difficulties identifying relevant nursing interventions.Does not prescribe relevant nursing interventions. Prescribes interventions from the perspective of other health professionals.
Being skillfulClear coherence between the different steps in the nursing process. Well-developed holistic approach.Clear coherence between the different steps in the nursing process. It is possible to understand prescriptions and evaluate the efficacy of prescriptions and changes in status.Little coherence between the different steps in the nursing. Difficult to follow the nursing care plan and understand how the patient should be treated and how outcome will be measured.No coherence between the different steps in the nursing process. Superficial description of the nursing care plan. Very difficult to follow the nursing care plan
Effective reflecting involves:
Evaluation/self-analysisIndependently evaluates and analyzes personal clinical performance, noting decision points, elaborating alternatives, and accurately evaluation choices against alternativesEvaluates and analyzes personal clinical performance with minimal prompting, primarily major events or decisions; key decision points are identified and alternatives are considered.Even when prompted, briefly verbalizes the most obvious evaluations; has difficulty imaging alternative choices; is self-protective in evaluation personal choices.Even prompted evolution are brief, cursory, and not used to improve performance; justifies personal decisions/choices without evaluating them.
Commitment to improvementDemonstrates commitment to ongoing improvement; reflects on and critically evaluates nursing experiences; accurately identifies strengths and weaknesses and develops specific plans to eliminate weakness.Demonstrates a desire to improve nursing performance; reflects on and evaluates experiences; identifies strengths and weakness; could be more systematic in evaluating weakness.Demonstrates awareness of the need for ongoing improvement and makes some effort to learn from experience and improve performance but tends to state the obvious and needs external evaluation.Appears uninterested in improving performance or unable to do so, rarely reflects; is uncritical of himself or herself or overly critical (given level of development); is unable to see flaws or need for improvement.
Authors

Ms. Georg is PhD Student and Lecturer, and Dr. Karlgren is Senior Researcher, Department of Learning, Informatics, Management and Ethics, Dr. Ulfvarson is Associate Professor, and Dr. Jirwe is Associate Professor, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm; and Dr. Welin is Associate Professor, Division of Nursing Science, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.

The authors have disclosed no potential conflicts of interest, financial, or otherwise.

The authors thank Professor Kathie Lasater, Oregon Health & Science University, for allowing them to modify the Lasater Clinical Judgment Rubric (LCJR) for use with virtual patients. They also thank the nursing students who participated in this study; the researchers, nursing teachers, and clinical nurses who participated in revising the draft of the virtual patient LCJR; and Dr. Mesfin Kassaye Tessma for help with the statistics.

Address correspondence to Carina Georg, MSN, RN, PhD Student and Lecturer, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18a, 171 77 Stockholm, Sweden; e-mail: carina.georg@ki.se.

Received: July 27, 2017
Accepted: March 06, 2018

10.3928/01484834-20180618-05

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