During my time as a prelicensure nursing professor, I noticed that students developed a sharper sense of decision-making after more repetitive exposure to simulations. Simulations in healthcare can involve using a simulator, which is a computerized mannikin that can respond or initiate vocal or human-like responses to their environment and those interacting with it. It is controlled by a simulation technician or another nursing faculty, typically behind the scenes, without students’ awareness of what the simulator will do next. Another option is using actual live actors who have been scripted to perform according to a scenario and respond to students in ways that cue students to perform tasks, make decisions, and even challenge them.
While conducting my doctoral research, I observed two groups of students (beginner and advanced) who showed marked differences in their abilities to respond to different levels of simulation scenarios. I used a tool called the Lasater Clinical Judgment Rubric (LCJR) (Lasater, 2007), which is based on Tanner’s Model of Clinical Judgment (Tanner, 2006). I compared these two groups of students using quantitative and qualitative analysis and noticed both groups were able to grasp the need and urgency to develop clinical judgment. Results showed statistically significant differences with a p>.001 with moderate to strong Cohen’s d values of real-world application.
According to industry research, newly graduated nurses lag in exercising the use of clinical judgment that is necessary to provide safe and effective patient care. In addition, older, more seasoned nurses are retiring at a faster rate than they can be replaced. Compounding this is the large efflux of seasoned nurses post-COVID-19 pandemic, leaving most acute facilities with staffing largely made up of traveler nurses and new graduate nurses. Many of these newly graduated nurses are burning out and leaving the profession within their first year of practice (Hayden, Smiley et al., 2014; Ironside & McNelis, 2009; Kavanagh & Szweda, 2017; Labrague & De los Santos, 2020; Pogue & O’Keefe, 2020).
This study used a mixed method convergent parallel quasi-experimental and case study approach comparing 128 pre-licensure students, dividing equally between beginner and advanced levels, as groups participated in high-fidelity simulation (HFS) and multi-patient simulation (MPS) experiences. The HFS included a simple Crohn’s case for the beginner group, while the advanced group participated in more complexity to include the MPS of a busy emergency department and HFS code blue cardiac arrest scenario. While the t-test quantified statistically significant differences in LCJR scores (p<.001), qualitative themes emerged to include confidence, prioritizing, fear, communication, problem-solving, and patient safety. These themes were cross-checked using triangulation and peer review. Most resoundingly, both groups expressed the desire to improve and identified how to improve, while the beginner group needed more prompting from the simulation facilitator post-simulation during the debriefing period.
My study validated other studies conducted showing statistical results supporting the use of simulation in the prelicensure nursing program to help increase students’ clinical judgment skills prior to graduation. The LCJR highlights 11 subsets to include Noticing (Focused Observations and Seeking Information, and Recognizing Deviations from Expected Patterns), Interpreting (Prioritizing Data and Making Sense of Data), Responding (Clear Communication, Clear and Confident Manner, Well-Planned Intervention and Flexibility, and Being Skillful), and Reflection (Self-Analysis/Evaluation and Commitment to Improvement). These subsets were analyzed for qualitative differences, illuminating the breadth and depth of how clinical judgment manifests itself. The LCJR has been studied over the years and has been shown to be a reliable and valid measuring instrument (Aldosari et al 2021; Cantrell et al, 2021; Klenke-Borgmann et al, 2020; Lee, 2021; Manetti, 2018; Nunes et al, 2020; Victor-Chmil & Larew, 2013; Vreugdenhil & Spek, 2018).
Along with focusing on clinical judgment itself, studies have shown simulation can better prepare nursing students for the real world as compared to basic testing procedures (Sherrill, 2020). Studies also used similar simulations to include MPS and Code Blue HFS illustrating how advanced students acquire more in-depth clinical judgment as they progress through their prelicensure nursing program (Alt-Gehrman, 2019; Blakeslee, 2020; Deschênes et al., 2019; Franklin et al, 2020; Kavanagh and Szweda, 2017; Klenke-Borgmann et al., 2020; Lawrence, 2018; Pogue and O’Keefe, 2020; Sherril, 2020; Victor et al, 2021; Whiffen, 2020; Franklin et al., 2020). This study qualifies with many quantitative studies using qualitative results, helping administrators further appreciate how simulation can help nursing students learn to “think like a nurse” (Tanner, 2006).
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