The National Council of State Boards of Nursing's (NCSBN, 2018) Strategic Practice Analysis identifies nursing clinical judgment as being number one on the top 10 high-priority skills for nurses. Nursing clinical judgment is an essential skill of the profession, but one that is often difficult to measure in assessment (NCSBN, n.d.). Nurse educators are challenged to develop quality evaluation methods that assess students' higher-order cognitive constructs, which are needed to set priorities in a clinical situation and to respond to changes in a patient's condition (Benner, Sutphen, Leonard, & Day, 2010). Furthermore, this faculty team has kept abreast of the research being conducted by NCSBN regarding potential upcoming changes to the NCLEX-RN®. As educators, it is imperative for faculty to provide rehearsal and practice with assessment items measuring entry-level nursing competence similar to the Next Generation NCLEX (NGN) project (Naeem, van der Vleuten, & Alfaris, 2012) to ensure student readiness for any upcoming changes to the licensure examination.
Historically, nursing clinical judgment has been described as a process by which a nurse decides on the data to be collected about clients, interprets the data, arrives at a nursing diagnosis, and identifies appropriate nursing actions (Miller & Keane, 2003). Nursing clinical judgment involves problem solving, decision making, and critical thinking (Miller & Keane, 2003). Nurses deal with a wide range of issues that are related to the condition of each patient, including complications and improvements, in addition to annotations to clinical records and communications with physicians (Phaneuf, 2008). Therefore, it is essential for nurses to possess sound observation and reasoning skills to make informed and reliable clinical judgments.
The NCSBN recognizes the increasingly complex decisions newly licensed nurses make during the course of patient care. Thus, the most recent definition from the NCSBN (2018) defines clinical judgment as “skill in recognizing cues about a clinical situation, generating and weighing hypotheses, taking action and evaluating outcomes for the purpose of arriving at a satisfactory clinical outcome” (p. 3). The latest research suggests nurses must possess both underlying mental processes of critical thinking and decision making to engage in effective clinical decision making (Muntean, 2012; Papathanasiou, Kleisiaris, Fradelos, Kakou, & Kourkouta, 2014).
This article describes a performance improvement project undertaken by a state system supported baccalaureate nursing program in the area of critical reasoning. As part of assessing students' learning outcome of critical reasoning, data identified the program was not meeting the benchmark as measured by Educational Benchmarking Inc. (EBI), Assessment Technologies Institute (ATI), and Health Education Systems Inc (HESI) scores. This article presents the theoretical underpinnings driving this project, describes the methods used for development and implementation of teaching and assessment strategies aimed at improving nursing students' clinical judgment, and identifies the next steps for this ongoing improvement project.
Acquiring the knowledge and skills needed to make sound clinical is a complex process. Mastery of nursing clinical judgment presents problems for educators, both from a teaching perspective and from an assessment or measurement standpoint. Traditional nursing clinical judgment models historically have been two-dimensional and linear, and often fail to capture the entirety of this cognitive exercise.
Muntean (2012), in a review of the literature on nursing clinical judgment, highlighted three nursing clinical judgment models: the humanistic-intuitive model, the cognitive continuum theory, and the information-processing model. Muntean's work illuminates the complexity of the nursing clinical judgment construct and the numerous cognitive attributes that are involved when nurses make decisions. Dickinson et al. (2016), in response to Muntean's work, proposed a framework for designing a theory-based assessment of higher order cognitive constructs such as nursing clinical judgment. The tasks captured in the model by Dickinson et al. (2016) reflected the five iterative processes that Muntean believed underlie the process of nursing clinical judgment: recognizing cues, generating hypotheses, judging hypotheses, taking action, and evaluating outcomes. Indeed, these iterative processes capture much of the work by known scholars in mathematics, nursing argumentation, and inquiry (Benner, 2000; Bertling, Jackson, Oranje, & Owen, 2015; Meirav, Ward, Thomas, Deonovic, & Von Davier, 2019; Sparks & Deane, 2015).
As educators, we were well aware that some of our students were not achieving the higher-level thinking processes needed for today's entry-level nurses. Establishing a clear understanding of nursing students' cognitive thought processes when participating in activities assessing higher-order cognitive constructs of nursing clinical judgment and understanding how to influence this process poses a challenge for many faculty. Constructs are often difficult to measure for several reasons. Dickinson et al. (2016) noted that a higher-order cognitive construct is usually an abstract, integrated cognitive practice, such as understanding a concept or creating a verbal or written product. This creates a challenge to capture the underlying mental activities that contribute to an individual's decisive action.
Dickinson et al. (2016) also described the intricacy of higher-order cognitive constructs, which often consist of multiple interdependent, sometimes recurrent or connected, cognitive operations. Students may have many layers of thought occurring based on their individual internal and external knowledge. Students may be continuously making intermediate decisions before arriving at a final answer. Conversely, students also may have detracting processes that are impeding the decision making process. As faculty seeking to improve student performance in the area of clinical judgment and decision making, we needed to create learning experiences that allow students to develop the ability to engage in cognitive operations needed to construct appropriate interventions. In addition, improved strategies were needed to effectively measure and assess students' ability to engage in the decision making processes necessary to perform well on unit examinations, enter into practice, and foster success on test items such as those proposed on the NGN.
The impetus for this project was identified from the university's systematic program assessment plan (SPAP), which identified students were not meeting the benchmarks on several data sources that measured critical reasoning. This student learning outcome is closely linked to nursing clinical judgment, as defined in SPAP for our undergraduate program:
The graduate makes decisions regarding client care utilizing cognitive and evaluative processes through questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity. Concepts used to meet the undergraduate nursing outcome of critical reasoning include: informatics (QSEN), evidence based practice (QSEN/Essentials), quality improvement (QSEN), clinical problem solving, and decision making.
Clinical Judgment Project
Nursing faculty are challenged to encourage high-level thinking in nursing students to ensure safe, quality patient care. As an initiative to increase nursing clinical judgment in undergraduate nursing students, nursing faculty representing all levels of a baccalaureate nursing program collaborated to focus on improving nursing clinical judgment throughout the curriculum as part of a data-driven performance improvement plan for the student learning outcome of critical reasoning. In addition, as noted by Kantar and Alexander (2012), new studies are needed to determine best teaching and assessment practices that enhance clinical judgment.
To facilitate this, a formal teaching circle was formed. The university's Center for Teaching Excellence supports faculty and encourages reflective and effective teaching through the establishment of teaching circles. Teaching circles are faculty-led groups that are established to enhance teaching in a supportive, caring, and collegial manner. They are typically 1-year commitments, composed of faculty interested in a particular theme and aimed at a unique teaching learning issue. In the authors' department, seven faculty formed a teaching circle focused on the teaching and assessment of nursing clinical judgment. Figure 1 depicts the life cycle of a teaching circle. As a result of the department's systematic assessment plan, obvious programmatic improvement areas emerged. The use of the teaching circle was an effective avenue for meeting the department's specific needs. Faculty self-selected into the group.
Life cycle of a teaching circle.
The team constructed the goals and objectives for infusing clinical judgment throughout the curriculum. The aims of this project were to discuss an overview of clinical judgment, apply clinical judgment to the undergraduate nursing program, and provide examples of clinical judgment in specific nursing courses within the present curriculum.
As part of the implement interventions and strategies, the team met regularly throughout the academic year to work on this project. The team articulated a shared mental model for approaching infusion of clinical judgment into the current undergraduate nursing curriculum based on the work of Dickinson et al. (2016).
As there is substantial research to support faculty development on item writing, the team applied for and received internal grant funding from the university to support this initiative (Naeem et al., 2012). The funding supported the purchase of an online webinar course as well as textbooks for teaching circle members. The webinar, Test Development and Item Writing, is an online course (NCSBN, n.d.) to enhance item writing, and the textbooks supported faculty development on item writing. Members of the teaching circle viewed and discussed the webinar, participated in literature review activities and discussions, and engaged in peer review of members' assessment items for use in both clinical postconferences and formal assessments of student learning (unit examinations) across all three levels of the program. Following faculty development for the members of this team, the information was disseminated during two workshops presented as lunch and learn professional development hours attended by other nursing faculty.
The first lunch and learn workshop focused on providing an overview of clinical judgment as the number one priority skill for new graduates (NCSBN, 2018). An overview of traditional item writing styles was presented, as well as the nursing clinical judgment model and the suggestions by Dickinson et al. (2016) related to item writing. To further enhance faculty members' item writing skills, test item analysis strategies were reviewed as one way to improve item writing. The value of test mapping was clearly articulated. The session moved into a hands-on approach with faculty sharing some of their own questions and using the group's input to advance test items from assessing knowledge or comprehension to application and analysis using Bloom's taxonomy.
The second lunch and learn workshop involved a variety of strategies to improve clinical judgment in the classroom, clinical, and simulation settings. This presentation started with an explanation of the content on the multilayer assessment model of nursing clinical judgment (Figure 1) established by Dickinson et al. (2016). The multilayered model was described, and opportunities for embedding this in individual theory and clinical courses were discussed. Demonstration of debriefing and case study examples were included in the presentation, focusing on layers 2 and 3 (construct layers) and layer 4 (context layer) of the Assessment Model of nursing clinical judgment (Dickinson et al., 2016). Original case studies and an unfolding case situation were shared that had been developed by members of the teaching circle and that are currently used in clinical post-conferences.
In an effort to infuse NGN assessment, albeit formative into primarily simulation and practice, a model for reflections was shared with faculty during the second lunch and learn. An advocacy/inquiry model, the PAAIL (Preview, Advocacy1, Advocacy2, Inquiry, and Listen) pneumonic, was shared for debriefing with students (Fey, 2017). Debriefing allows for the faculty to ascertain and measure where a student is at in the learning process in real-time. Although debriefing often is used at the conclusion of an activity, its value throughout the learning experience has been noted. The National League for Nursing (NLN, 2015) acknowledges and supports the value of debriefing in various settings, including clinical and simulation. Faculty shared experiences of applying PAAIL in clinical settings and collaboratively discussed opportunities to use debriefing as a way of further developing students' clinical judgment.
Building on the first workshop, item writing was expanded to include a discussion of NGN questions that assess clinical judgment. Finally, Clinical Conversations: The NLN Guide to Teaching Thinking (2016) was presented along with a clinical scenario example. This thinking guide focused on the learner describing the patient situation, understanding the thinking that occurred, and then determining how the thinking will be used in practice (NLN, 2016). At the conclusion of this second workshop, all faculty reflected on how clinical judgment could be further developed in each course and throughout the program. This work, as a gap identified through our programmatic systematic assessment plan, was ultimately closed as the workshops brought teaching practice full circle for our faculty. Future directions include sharing and disseminating information though consultations, presentations, and manuscript submission.
Incorporating the nursing clinical judgment model into the curriculum is an ongoing part of the university's current improvement plan. The lunch and learn sessions were well received, and faculty benefitted from the teaching circle's professional development activities by gleaning tools to develop, measure and assess clinical judgment with undergraduate nursing students in nursing courses. Faculty continue to develop rigorous questions to assess clinical judgment using high-level NCLEX style questioning formats while infusing teaching strategies into simulation, clinical, and theory courses.
Faculty continue to use peer review of test items and quantitative data analysis of item performance when writing and refining test questions. Student performance on these items designed to assess nursing clinical judgment are analyzed and examined for trends. Examples of individual item analysis statistics that are collected and reviewed include the p value for average values of the items to assess difficulty, point biserial index to depict the discrimination ability of an item, and p values for the percentage of students choosing the correct responses as well as for each of the item distractors.
To assess how well the strategies have worked, faculty have adopted assessment strategies designed to capture student cognitive processes, such as those identified in the nursing clinical judgment model (Dickinson et al., 2016). In addition to traditional NCLEX style questions on examinations, items also now include scenario-based, unfolding cases, and the use of data reflective of evolving patient care situations. Additional assessment strategies have been included in simulation and clinical settings, such as the unfolding case studies, guided reflective thinking, and debriefing approaches. Ongoing work to improve nursing clinical judgment will include continued monitoring of the student learning outcome of clinical reasoning as dictated by SPAP.
To foster ongoing professional judgment, members of the teaching circle have disseminated our findings to another baccalaureate program in a consultation format. Future research is planned to include a quantitative study examining student performance when testing nursing clinical judgment using some of these newly developed items compared with traditional measurement strategies. In addition, as part of the outcomes assessment plan, collected employer survey data will assist with determining whether students have improved skills for clinical decision making necessary in new graduates.
Professional faculty development in the application of clinical judgment teaching and assessment strategies is necessary if emerging professionals are to deliver quality care when transitioning to new graduate roles. The use of a faculty teaching circle is one way to foster professional development and program improvement strategies related to the development of students' use of nursing clinical judgment in baccalaureate nursing programs. The nursing clinical judgment model provides a more advanced understanding of students' thought processes and may help to provide a better understanding of students' cognitive development skills. As faculty continue to explore the use of best evidence for practice, adoption of the nursing clinical judgment model earlier in the learning process may facilitate professional transition for new graduates. Incorporating this model of nursing clinical judgment using high-level case studies, examination questions, and debriefing in clinical, classroom, and simulation settings will better prepare students for readiness to enter the complex health care environment.
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