Journal of Nursing Education

Major Article 

Development of a Clinical Judgment Measurement Model-Based Simulation Module for Ileus: A Mixed-Methods Study

Aeri Jang, PhD; Suhyun Kim, PhD; Mi Ok Song, PhD



Despite the increasing prevalence of simulation education, a specific clinical judgment measurement model-based simulation module for ileus has yet to be developed.


Using a mixed-methods research design, quantitative data were collected through a survey, and qualitative data were collected through reflective journals. Collected data were used to develop a simulation module, which subsequently was implemented with 88 nursing students from Korea.


Quantitative analyses confirmed the module effectively improved participants' knowledge of ileus, clinical skill, and performance ability. Qualitative analysis of the journals identified five themes and 11 subthemes in three domains.


The developed scenario effectively enhanced nursing students' learning, implying that similar modules for various diseases may help students to acquire necessary nursing skills. However, current results cannot be generalized; a more accurate analysis of its effects requires further and repeated studies to compare clinical decision-based simulation modules with modules that apply different learning methods. [J Nurs Educ. 2020;59(7):382–387.]



Despite the increasing prevalence of simulation education, a specific clinical judgment measurement model-based simulation module for ileus has yet to be developed.


Using a mixed-methods research design, quantitative data were collected through a survey, and qualitative data were collected through reflective journals. Collected data were used to develop a simulation module, which subsequently was implemented with 88 nursing students from Korea.


Quantitative analyses confirmed the module effectively improved participants' knowledge of ileus, clinical skill, and performance ability. Qualitative analysis of the journals identified five themes and 11 subthemes in three domains.


The developed scenario effectively enhanced nursing students' learning, implying that similar modules for various diseases may help students to acquire necessary nursing skills. However, current results cannot be generalized; a more accurate analysis of its effects requires further and repeated studies to compare clinical decision-based simulation modules with modules that apply different learning methods. [J Nurs Educ. 2020;59(7):382–387.]

Ileus is a common and frequent occurrence after abdominal surgery (Chapman et al., 2018). Delays in its diagnosis and treatment may lead to life-threatening symptoms and complications, such as perforation (Murphy et al., 2016). Nurses should have professional competencies, with knowledge of clinical judgment being one competency, that would enable them to manage patients suffering from ileus. However, nursing students often have little to no clinical experience in managing ileus.

The importance of nurse involvement in patient diagnosis has been increasingly emphasized in recent years (Cahill et al., 2019). Although simulation education increasingly is becoming inclusive, representation of the nursing activity process remains incomplete (Ham, 2009; National League for Nursing, 2019), and there is little discussion on how to prepare nursing students to participate in patient diagnosis. The National Council of State Boards of Nursing (NCSBN) Clinical Judgment Measurement Model (CJMM) is a reliable framework that exhibits the process of clinical judgment (Dickison et al., 2019; NCSBN, 2019) and therefore can help students implement safe clinical practice when applied to the curriculum. Accordingly, scenario development based on CJMM in a simulation module is believed to be effective in helping nursing students learn nursing activity processes more effectively (Hensel & Billings, 2020).

To assess the simulation experiences of nursing students, previous studies have used a debriefing strategy to improve students' clinical judgment (Al Sabei & Lasater, 2016). This debriefing strategy was based on CJMM (Jeong & Choi, 2017) and the Lasater Clinical Judgment Rubric (Cato et al., 2009; Yang et al., 2019). However, research regarding the application of CJMM to simulation or ileus simulation scenarios for nursing students is lacking. Consequently, CJMM can be maximized by integrating simulation and the instructional design for ileus. To address the need to integrate this process in simulation education, this study developed and evaluated the effectiveness of a CJMM-based ileus simulation module for ileus patients.


Study Design and Participants

This study used a mixed-methods design that incorporated two methods: a simulated control group study design (Park et al., 2016) and reflective journal analysis. Study participants were third-year nursing students from a nursing college located in G Metropolitan City, Republic of Korea. The students, who participated voluntarily, were taking an adult nursing class that included a course on the digestive system. The calculated sample size was 72, in consideration of a 0.25 effect size and a 95% confidence level. In total, 90 students were recruited with consideration for dropout rates, which then decreased to the final number of 88 (n = 44 students in the experimental group and n = 44 students in the control group) (Figure 1).

Study process.

Figure 1.

Study process.

CJMM Ileus Simulation Module Development

The goals and operationalization of the simulation scenarios were established using a conceptual framework in consideration of available facilities, equipment, and space. Supplementary teaching materials, along with preliminary learning materials for the scenario and a video clip that explained the theoretical knowledge and activities required to run the scenario, were provided. The CJMM ileus simulation module operations used a high-fidelity simulation based on the simulation model by Jeffries et al. (2015) to organize the pre- and postinvestigation variables.

The module developers presented lecture notes in a video format, a handout for the students, and a simulation scenario. The setting of medical treatment and preventive aspects for this scenario were established based on the study results of Venara et al. (2016), incorporating the CJMM (Dickison et al., 2019) in its design. The developed scenario was validated by a clinical nurse who had worked in a surgical ward for more than 5 years, a professor in nursing simulation, a professor in adult nursing, and a specialist in internal medicine. Each scenario's validity was verified by collecting experts' opinions on its appropriateness via email. The scenario then was revised based on their opinions, pilot tested, and supplemented for finalization (Figure 2).

Module operation process.

Figure 2.

Module operation process.

In the developed scenario, the patient was a 70-year-old woman who underwent laparoscopic anterior resection for sigmoid colon cancer. She started a liquid diet 4 days after surgery. For the scenario setup, the patient was given a laboratory test and a radiographic examination after arriving on the ward. Laboratory tests and abdominal radiographs, including a general script, abdominal circumference, body weight chart, and log sheet, were provided. The specific scenario flow is shown in Table A (available in the online version of this article). Teams included four participants: one charge nurse, two acting nurses, and one nursing recorder.

Scenario FlowScenario FlowScenario Flow

Table A:

Scenario Flow

Effect of the Module

Factors that could affect the problem-solving process, such as metacognition (Kang et al., 2008) and self-deterministic learning motivation (Lee et al., 2017), were measured to verify homogeneity between the experimental and control groups. The metacognitive strategy instrument of Yang (2000) and the self-determination learning motive questionnaire of Ryan (2004) for Koreans (Park et al., 2005) were used. In the development phase, Cronbach's alpha was .75 and .86 for the experimental and control groups, respectively. In the current study, the values were .91 and .90 for the experimental and control groups, respectively.

Questions from three categories were derived to examine the participants' ability to perform the clinical judgment for ileus patients: 1) 7 questions on self-confidence, 2) 10 questions on theoretical knowledge, and 3) 25 questions on clinical activity. Each category was validated by two adult nursing professors and two clinical nurses. Questions with content validity index with a cut-off score ≥1.0 were selected. For categories one and three, Cronbach's alpha was set at .95. Participants' degree of self-confidence was measured using a 5-point Likert scale. For theoretical knowledge, scores ranged from 0 to 10 points, and for clinical activity, scores ranged from 0 to 50 points. A higher score indicated higher self-confidence, knowledge, and clinical activity.

Ethical Consideration

Ethical approval was obtained from the bioethics committee of the public institution designated by the Ministry of Health and Welfare (IRB No. PO1-201811-13-002). The study's purpose and process were verbally explained to all participants. Written and informed consent was obtained from each participant after a full explanation regarding their participation was provided. For students to receive the same educational opportunities, the control group received the same CJMM ileus simulation module.

Data Collection

The experimental and control groups were selected according to the order of participant registration. Because the participants' gender might affect simulation results (Díez et al., 2013), it was ensured that both groups would include a similar number of male and female participants. The pretest of the control group and posttest of the experimental group were administered at a 1-week interval to prevent the diffusion of experimental effects. The study was conducted from November 24 to December 14, 2018, at a university in South Korea.

This study investigated the general characteristics of participants after orientation through a pretest of the control group with general characteristics. The experimental group then performed self-learning through the 60-minute video provided online. A posttest subsequently was conducted after 1 week. The experimental group also was instructed to submit reflective journals in each module phase.

Data Analysis

Collected data were analyzed using SPSS® version 20.0. Chi-square was used to analyze the general characteristics and homogeneity of the groups, and the t test examined self-confidence, knowledge, and clinical ability of the control group before the intervention with that of the experimental group after the simulation. The reliability of the instrument was tested using Cronbach's alpha coefficient.

Qualitative data were analyzed using the reflective journals of the experiment group. As the first step of the analysis, after meaningful statements in each stage of the CJMM ileus simulation module (presimulation operation, simulation operation, and postsimulation) were extracted and arranged inductively, the process of integrating similar content was repeated. In the second step, based on the qualitative content analysis of Graneheim and Lundman (2004), themes, categories, and sub-categories were extracted by comparing these classes based on data. For auditability, a group of nursing educators and education experts repeatedly reviewed all coded data and categories throughout the analysis process.


The two groups were verified to be homogenous. After the simulation, results showed self-confidence in the experimental group was significantly lower (p = .003) than in the control group. However, knowledge score and clinical ability in the experimental group were significantly higher (p < .005) than in the control group. Qualitative analysis of the CJMM ileus simulation module resulted in the derivation of three domains, five themes, and 11 subthemes (Table 1).

Qualitative Analysis of Students' Experience of the Clinical Judgment Measurement Model-Based Simulation for Ileus Patients

Table 1:

Qualitative Analysis of Students' Experience of the Clinical Judgment Measurement Model-Based Simulation for Ileus Patients


The CJMM ileus simulation module enabled students to maximize their nursing experience for patients suffering from ileus. In terms of self-confidence, the results indicated the level of self-confidence was lower in the experimental group than in the control group after simulation-based learning. This finding is similar to previous studies in which a lower confidence level was observed after simulation-based learning in the experimental group (Blum et al., 2010; Brown & Chronister, 2009). Self-reports of confidence levels may be of limited value because there is an uncertain relationship between the level of perceived confidence and the reality of independently observed competence of health professionals (Davis et al., 2006). As confidence is a definitive educational goal, short-term education cannot effect significant changes. Self-confidence affects the ability to conduct clinical practice by integrating knowledge and firsthand experience. Students can gain self-confidence through sufficient support and feedback from instructors and repeated exposure to nursing situations (Lee et al., 2009; Park & Hong, 2019).

In terms of knowledge, the current study found a significant increase. This finding is in contrast with the results of a previous study that found no significant increase in knowledge after simulation-based learning (Ham, 2009). The cognitive learning effect could have been enhanced in the current study with the integration of the clinical judgment-based scenario flow and debriefing. Flipped learning through video clips and clinical experience through simulation enabled both theoretical and empirical learning. The situation was analyzed through a group discussion before the simulation. Therefore, their understanding of the scenario might have increased by recognizing and analyzing cues, prioritizing hypotheses with the clinical judgment process during postscenario operation, concept mapping, and handover.

Similarly, the level of clinical ability also improved significantly in this study. Kim et al. (2013) reported that many previous studies evaluating the psychomotor area—the main objective of simulation training—showed similar results. Clinical elements of nursing education are necessary to determine how knowledge can be used in the profession (Jeffries, 2005; Norman, 2012). The current findings suggest that improving the performance ability and clinical skill of nursing students related to ileus patients is essential.

Analysis of the reflective journals found that participants acquired a comprehensive understanding of clinical situations through the CJMM ileus simulation module. This allowed participants to concentrate more on solving the nursing problem. Unlike previous studies, the current study allowed participants to conduct suitable activities without deviating from the scenario due to cues set in place. Content analysis of the reflective journals also showed the students were confident in nursing practice through cues and realized the importance of critical thinking through answering clinical questions fostering nursing capability. Thus, it can be assumed that the developed CJMM ileus simulation module can improve the learning effect systematically. However, simulation programs based on the NCSBN-CJMM confirming the effectiveness of such simulations have been rare. Therefore, it is necessary to develop various clinical cases and organize educational programs.

Despite the positive results found in this study, the limited sample size makes generalizability difficult. Although efforts were taken to ensure contact between the control and experimental groups was minimal to prevent mutual ripple effects, complete control could not be assured. The use of the self-reporting method also can result in subjective interpretation, consequently leading to some errors in measurement.


Unlike previous simulation programs, this study incorporated the NCSBN-CJMM into the simulation module and suggested instructive strategies. It also has merit in that it suggests underlying data for establishing simulation classes and provides an alternative learning method that could replace clinical practicum and theoretical classes. However, research is still needed to compare the educational effectiveness of CJMM on various clinical cases. In addition, practical use and effectiveness of clinical ability and knowledge acquired from simulations in clinical practices also should be explored. Further research also can explore the correlation between low self-confidence and high clinical ability. More importantly, studies on the establishment of various plans and strategies to achieve theoretical learning and clinical ability through simulations should be conducted.


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Qualitative Analysis of Students' Experience of the Clinical Judgment Measurement Model-Based Simulation for Ileus Patients

DomainThemeSubthemeSample Responses
Presimulation operationPreliminary education compositionLearning efficiency“I was able to save time as I could watch it on the bus.”
Learning effectiveness“Unlike the clinical records of an unknown patient, I could remember better in doing clinical practice as I can see the instructors' practice.”
Keeping study initiative“Watching a video lecture before the simulation is more interesting than a lecture-based class.” “As I listened to the instructor's handover at the last part, it felt as if I just became a real nurse, and it was fun.”
Simulation operationCueSelf-confidence on nursing practice“I felt great responding to the patient's questions using what I have learned in the preliminary education.”
Self-acknowledgment of parts with academic insufficiency“I was embarrassed when a patient asked questions that I had never even thought of. I think I have to study anatomy and physiology again.”
ScenarioRealistic nursing experience“While other clinical practices were centered only on observations, the simulation felt like I was actually doing it.” “As this scenario proceeded based on the nursing process, I was able to understand the process of going through rounds in a ward, explaining, mediating during work hours, and performing nursing evaluation by ward round before getting off work.”
Learning from mistakes“I mistakenly injected KCL as I did not know its components. Now, I will never repeat the same mistake.”
Integration of theoretical and practical knowledge“It was an opportunity to learn how theoretical studies can be applied to clinical practices.”
Fostering nursing capability“I feel like grounded critical thinking is highly important.” “I can now practice nursing with questions like, ‘Why do they have these symptoms?’ and ‘Why did this occur?’” “I learned the importance of communication.” “As I did it with colleagues and I was not alone, it was less burdensome and more fun.”
Postsimulation operationConcept mappingUnderstanding the scenarios“Through concept mapping, I have better organization of various scenarios.”
HandoverAcknowledging the importance of handover“I did not know the reason and practice of handover before, but now I understand its importance and contents.”

Scenario Flow

Cognitive ProcessMonitor settingSimulator actionExpected actionCue sign
If no reactionReaction
Recognize/analyze cues 0–6 minMental state: Alert HR: 68 BP: 120/80 mmHg RR: 20 times/minute SpO2: 100% T: 36.8°C EKG: Normal Bowel sound: Paralytic ileus Vocal sound: Vomiting, moaning in pain Saline solution 500 cc IV PCA kept on (not function) BV kept on (positive, 20 cc) I/O sheet hanging in patient's bed X-ray prescribed in the general description has just been filmed after time delay[Pt complains of abd pain]“I had a stomachache all night, and I couldn't sleep at all.” “I haven't expelled gas at all, and my stomach feels like it is twisted in knots!” “I want to expel gas, but the surgery site is tender. I cannot move too well. It's so painful.” “I wonder if the surgery didn't go well.” “I think my stomachache is worse than before the surgery.” “I have been feeling nauseous, and my stomach hurts.” “This evening, they gave me rice porridge, but I only ate a little because I couldn't eat well.” “I was so nauseous that I vomited. It was greenin color.” [Abd pain evaluation by nurses]RLQ ➔Spread as a whole, Stingy ➔Spreading aspect, NRS 7 points, Continued from 2 hr ago[Pt's nausea worsens after PRN injection]“Yuck! Yuck!” “I think I'm going to puke. Please give me a plastic bag.” “Why does my stomach still hurt even though I took a pain reliever?”Self-introduction V/S O2 saturation check Diet level check Intake/output check Abdomen assessment Nausea and vomiting check Medical history check Nutrition state Mobility Age check Anxiety check BW AC check X-ray result check 6:00 a.m. laboratory check IV PCA function check BV check Pain levelCheck dietary intakePt“Although porridge was provided for supper yesterday, I hardly ate it.”
Check abd inflation“I feel bloated, like my stomach is full of gas.”

Check BW and AC“I feel like my stomach is inflated.”
Check morning test results“How were the morning X-ray and blood test?”
Check IV PCA function“Is this being injected properly? I think it's useless.”

Check mobility“A doctor told me to move around, but I couldn't.”

Check the X-ray result, contact as follows to keep flow (as a Ptjust had X-ray)Dr“Have the X-ray results come out?”

Check the morning laboratoryContact to proceed laboratory check

Prioritize hypothesis1st clinical judgment: Dysfunctional gastrointestinal motility; cue check: immobility, operation, medication, gastrointestinal nutrition, abd pain compliant, nausea, vomiting, old age, postop state; IV PCA kept on, AC elevation, X-ray result, bed rest state; bowel sound, WBC elevation, unbalanced electrolyte 2nd clinical judgment: Risk of electrolyte imbalance; cue check: Vomiting, imbalance of water, oral intake poor, unlaced electrolyte, albumin, and Hgb decrease 3rd clinical judgment: Acute pain; cue check: Vomiting, factors causing damage, NRS 7 points; nausea sense; postop state; maintaining external invasive device

Generate solutions/take actions 6–12 minMental state: Alert HR: 100 BP: 80/50 RR: 32 times/min SpO2: 96% Temp: 36.8°C EKG: NormalBowel sound: Paralytic ileus Vocal sound: Vomiting, moaning in pain TPN 1250 44 cc/hr kept inplasma solution + KCL mixed fluid; IV PCA removal BV kept on (negative)[Doctor]“Did you check the X-ray results?” “How was the routine blood test result?” “I'll add one more blood test, similar to general laboratory. Please check the prescription.” “First, mix 10 mg metoclopramide, then administer via IV, please.” “First, ask the Pt to fast and then please connect the Ringer's solution.” “You're doing Pt ambulation, is that right? Please reeducate regarding active ambulation.” “After checking the X-ray result, it seems to require decompression. I'll insert the Levin tube.”Report to doctor based on SBAR NPO education Hot bag application Levin tube connect suction Plasma solution fluid start TPN start metoclopramide10 mg injection IV PCA education After anti-AST injectionCheck PRN for pain controlPt“Don't I get a painkiller after surgery? They said I could call a nurse when I feel pain.”

Report to an attending physician“Please call the attending physician.”

Educate about NPO“Would there be porridge for lunch?”

Check prescription on IV injection“Can I have a nutritional supplement injected during the fast?”
If one asks about the nonusage of IV PCAPt“I didn't press it deliberately for recovery, as it may cause dizziness.”

If one asks about whether you had education on IV PCA use“I think I have, but I can't remember.”
Explain regarding BV management“How long do I have to have a blood pocket?

Explain regarding antibiotics“Why are you injecting me with the shot?”

[Insertion of Levin tube by the doctor]Go to the simulation room, and perform a Levin insertion.“Please connect suction, and connect to the drain tube if it drains more than 300 cc.” “Is the Pt still wearing an IV PCA?”When you enter to do Levin insertion, send cues to conduct it properly.“Please connect this suction and when over 300 cc is drained, connect it to the drainage tube.” “Does the Pt still have IV PCA?” “Do Levin drainage. Check how much is being drained.” “Is PCA being properly injected?” “Check the laboratory work, and tell me the result.” “Is the Pt fasting?”
Evaluate outcomes 12–15 minHR: 88 BP:110/70 RR: 16breaths/minute SpO2: 100% Temp: 36.8°C EKG: Normal Levin tube kept on Bowel sound: Paralytic ileus TPN 1250 44 cc/hr kept on Plasma + KCL mixed fluid kept on IV PCA removal BV kept on (negative)[Pt]“Why am I doing this?” “What if I have these symptoms again?”Education on ileus Education on symptom Education for management of IV PCA and BV Levin tube drainage amount check BV drainage amount check Ambulation encouraged Hot bag application encouragedExplanation after inserting nasogastric tubePt“Can I move with this tube?”

Check whether woke up early and exercised“I kept lying on the bed as I was scared of stomach pain, but the pain seems to be worsening.”
Explain the symptoms of ileus“Why on earth do I have these symptoms? Did the surgery go bad?”

Perform debriefingWhy was the subject hospitalized? What was the situation of the subject in the scenario?What were the objective and subjective significant assessment data of the subject's situation? Based on the data, what nursing diagnosis was possible for the subject? List by priority of possible nursing diagnosesTalk about nursing interventions applied to each nursing diagnosis. What should be checked when evaluating nursing care for each nursing course?

Dr. Jang is Instructor, College of Nursing, Chonnam National University, and Dr. Kim is Assistant Professor and Dr. Song is Assistant Professor, Department of Nursing, Nambu University, Gwangju, Republic of Korea.

This study was supported by the National Research Foundation of Korea (NRF: 2017R1C1B5017463).

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

Address correspondence to Mi Ok Song, PhD, Assistant Professor, Department of Nursing, Gonghakjgwan, 2414, Nambu University, 23 Chumdan Jungang-ro, Gwangsan-gu, Gwangju, 62271 Republic of Korea; email:

Received: November 03, 2019
Accepted: May 04, 2020


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