Observed Use of Clinical Judgment Among New Graduate Nurses.

BACKGROUND: Despite the efforts of academic nursing educators to prepare students to make sound clinical judgments, the literature suggests new graduate nurse (NGN) competence with this critical skill continues to decline. This study sought to identify how practicing nurses describe their observations of the use and outcomes of clinical judgment by NGNs in nursing practice. METHOD: A multisite, cross-sectional survey using multiple-choice, Likert scale, and open response items to identify participants' observations of NGN clinical judgment was sent with snowball sampling and resulted in a sample of 314 participants from 19 U.S. states. RESULTS: Practice partners identified a wide discrepancy between how they expect NGNs to use clinical judgment and what they actually see NGNs do, with resultant negative effects on patients and NGNs. CONCLUSION: These results provide a beginning understanding of NGNs' specific challenges with clinical judgment. Efforts to improve clinical judgment across nursing education and practice are needed. [J Contin Educ Nurs. 202x;5x(x):xx-xx.].

Current practices for assessing clinical judgment in nursing students and new graduates: A scoping review.

OBJECTIVE: To map current assessment practices for learning outcomes related to nurses' clinical judgment from undergraduate education to entry to practice. DESIGN: Scoping review using the Joanna Briggs Institute guidelines and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). DATA SOURCES: Electronic databases-Cumulative Index of Nursing and Allied Health Literature (CINAHL Complete; EBSCOhost), EMBASE (Ovid), MEDLINE (Ovid), PsycINFO (Ovid), and Web of Science (Social Sciences Citation Index, Citation Index Expanded)-using a combination of descriptors and keywords related to nursing students, newly graduated nurses, clinical judgment and related terms (e.g., critical thinking, clinical reasoning, clinical decision-making, and problem-solving), and assessment. METHODS: Two reviewers independently extracted study characteristics and, for each outcome relevant to clinical judgment, the concept, definition and framework, assessment tool, and the number and schedule of assessments. Data were synthesized narratively and using descriptive statistics. RESULTS: Most of the 52 reviewed studies examined the outcome of a discrete educational intervention (76.9 %) in academic settings (78.8 %). Only six studies (11.5 %) involved newly graduated nurses. Clinical judgment (34.6 %), critical thinking (26.9 %), and clinical reasoning (9.6 %) were the three most frequent concepts. Three assessment tools were used in more than one study: the Lasater Clinical Judgment Rubric (n = 22, 42.3 %), the California Critical Thinking Skills Test (n = 9, 17.3 %), and the Health Science Reasoning Test (n = 2, 3.8 %). Eleven studies (21.2 %) used assessment tools designed for the study. CONCLUSION: In addition to a disparate understanding of underlying concepts, there are minimal published studies on the assessment of nursing students and nurses' clinical judgment, especially for longitudinal assessment from education to clinical practice. Although there is some existing research on this topic, further studies are necessary to establish valid and reliable clinical competency assessment methods that effectively integrate clinical judgment in clinical situations at relevant time points.

Evolving the Assessment of Clinical Judgment: An Individual or Collective Competency?

BACKGROUND: Nurses make decisions about care individually and as part of a team. Collective competence, the effective team management of patient care situations, is partially dependent on nurses' individual confidence and clinical judgment competence. PURPOSE: To describe individual and team-based facilitators and barriers to collective competence in teams of senior baccalaureate-level prelicensure nursing students during a team-based simulation. METHODS: With a cross-sectional design, the study used a 26-item survey based on the National Council of State Boards of Nursing (NCSBN)-Clinical Judgment Measurement Model (CJMM) (α= .86) to assess individual student confidence and perceptions of clinical judgment competence while observation of team dynamics and task completion assessed collective competence. RESULTS: Closed-loop communication and role assignment were facilitators of collective competence when present and barriers when absent. Additional barriers were lack of student confidence and perceived competence with Layers 3 and 4 of the NCSBN-CJMM. CONCLUSIONS: Team-based simulation strategies can be effectively used to assess collective clinical judgment competence.

Current Practices for Teaching Clinical Judgment: Results From a National Survey.

BACKGROUND: Safe patient care is closely linked to clinical judgment. Concerns about inadequate practice readiness and the impending inclusion of clinical judgment items on the NextGen NCLEX have resulted in increasing interest and publications about teaching clinical judgment. However, little is known about actual current practices for teaching this skill. PURPOSE: This research describes findings about current strategies to teach clinical judgment used in US prelicensure nursing programs. METHODS: Cross-sectional methodology was used to survey program deans and directors across the United States. RESULTS: Programs are using multiple strategies to teach clinical judgment. The most common strategies used include case studies and simulation. Participants believed strategies have a positive impact on student thinking, practice readiness, and program outcomes. They described insights into implementation of teaching for clinical judgment. CONCLUSION: The results of this research provide foundational data to inform current teaching practices and further research for this essential skill.

Impact of COVID-19 on New Graduate Nurses' Transition to Practice: Loss or Gain?

BACKGROUND: The COVID-19 pandemic disrupted nursing education and required modification of instructional methods and clinical experiences. Given the variation in education, rapid transition to virtual platforms, and NCLEX-RN testing stressors, this cohort faced unique losses and gains influencing their transition into clinical practice. PURPOSE: This study examined the impact of COVID-19 and preparedness for professional practice of 340 new graduate nurses (NGNs) at an academic medical center. METHODS: This was a mixed-methods descriptive study focusing on how clinical experience loss or gains in the final semester affected the fears, concerns, and recommendations for NGNs. RESULTS: More than half (67.5%, n = 295) of NGNs reported changes to clinical experiences, ranging from 0 to 240 hours transitioned to virtual (n = 187; median, 51; interquartile range, 24-80). NGNs fear missing important details or doing something wrong in providing patient care. They identified the need for preceptor support, guidance, teaching, and continued practice of skills. CONCLUSION: Recommendations are clear communication with leadership, advocacy from the nurse residency program, and targeted clinical and emotional support for NGNs.

Optimizing the student learning environment: A framework to select faculty for teaching courses.

Nurse educators must provide high quality student education and demonstrate foundational competencies to fulfill the academic role. Reports on nursing and health care underscore the importance of nurse educators' clinical expertise and educational preparation in teaching; yet, a framework to framework faculty selection and preparation to teach courses does not exist. The purpose of this article is to describe an innovative Faculty-Course Selection Framework (FCSF) for nursing education and discuss two practical examples of application in one school of nursing. The FCSF describes student, organizational, and faculty elements for consideration in determining faculty-course assignment. The fundamental units of the framework include workload needs, credentials, skills, content interest, individual attributes, and commitment. The FCSF equips nursing program administrators and directors to cultivate a highly functioning faculty team that can achieve pedagogical, subject, social, and organizational competence to practice the nurse educator role skillfully and artistically and optimize the student learning environment.

Development and Pilot Testing of a Multidimensional Learning Environment Survey.

BACKGROUND: Multiple, complex factors comprise the learning environment and influence student learning outcomes, yet comprehensive evaluation of the learning environment in nursing schools is limited. PURPOSE: The Learning Environment Survey (LES) was developed to facilitate nursing students' report of perceptions of the complex learning environment in nursing education. METHODS: Systematic exploration of the literature, conceptual operationalization of the learning environment, and development of an item pool were completed. Content validity was established with expert assessment, student testing for clarity, and calculation of scale-content validity index/average (S-CVI/Ave). Pilot testing was completed at 1 school of nursing with baccalaureate-equivalent prelicensure and advanced practice master's level students, and doctor of nursing practice students. RESULTS: The CVI (S-CVI/Ave) was 0.92. Domain scores demonstrated Cronbach's α reliabilities of 0.67 or higher with most being > 0.85. CONCLUSION: The LES establishes a mechanism for eliciting comprehensive learning environment data for systematic assessment and national comparison of multiple nursing learning environments.

Teaching Prioritization: "Who, What, & Why?"

BACKGROUND: New graduate nurses must be equipped to prioritize the needs of multiple complex patients and intervene on problems causing the highest risk of adverse outcomes. Targeted and theoretically supported strategies to teach prioritization without significant change to clinical education structure are needed. METHOD: A structured, scaffolded prioritization exercise using individual and peer-learning strategies engages prelicensure nursing students in purposeful practice prioritizing care needs for individuals and groups of patients. The exercise uses students' assigned clinical patient data, during existing clinical conference sessions, across a three-semester clinical course sequence with baccalaureate-level prelicensure nursing students. RESULTS: Students appreciate the peer learning and coaching provided by instructors during this activity. Instructors identify that students more readily recognize potential and actual risks and prioritize nursing actions in conferences and clinical sessions. CONCLUSION: Simple and theoretically based teaching strategies offer a pathway for teaching students to recognize salient features of complex patient situations, prioritize actions, and provide safe patient care. [J Nurs Educ. 2019;58(5):302-305.].

Pursuing Improvement in Clinical Reasoning: The Integrated Clinical Education Theory.

BACKGROUND: The link between clinical education and development of clinical reasoning is not well supported by one theoretical perspective. Learning to reason during clinical education may be best achieved in a supportive sociocultural context of nursing practice that maximizes reasoning opportunities and facilitates discourse and meaningful feedback. Prelicensure clinical education seldom incorporates these critical components and thus may fail to directly promote clinical reasoning skill. METHOD: Theoretical frameworks supporting the development of clinical reasoning during clinical education were evaluated. Analysis of strengths and gaps in each framework's support of clinical reasoning development was conducted. Commensurability of philosophical underpinnings was confirmed, and complex relationships among key concepts were elucidated. RESULTS: Six key concepts and three tenets comprise an explanatory predictive theory-the integrated clinical education theory (ICET). CONCLUSION: ICET provides critical theoretical support for inquiry and action to promote clinical education that improves development of clinical reasoning skill. [J Nurs Educ. 2018;57(1):7-13.].

Influences of Sociocultural Factors Within the Clinical Learning Environment on Students' Perceptions of Learning: An Integrative Review.

A persistent deficit in new graduate nurses' clinical reasoning skill exists. Clinical reasoning is best learned in the sociocultural clinical learning environment (CLE), yet many CLEs fail to engage nursing students in the cognitive work of nursing that promotes development of clinical reasoning. Despite two decades of recommendations to improve CLEs based on students' perceptions of learning, widespread improvement remains elusive. OBJECTIVE: The aim of this review was to synthesize what is known about the influence of sociocultural factors in the acute-care CLE on prelicensure nursing students' perceptions of learning, for the purpose of identifying factors that when modified may promote improvement of clinical reasoning skill. METHOD: The integrative review methodology was used to synthesize and identify gaps in evidence on students' perceptions of learning in the acute-care CLE. RESULTS: Global commonalities exist in the impact of the sociocultural CLE on students' perceptions of learning, including overall sociocultural atmosphere, membership in the health care team, supervisory relationships, peer relationships, and clinical education structure. CONCLUSIONS: This review provides evidence that modification of CLE factors and examination of their influence on measurable learning outcomes such as clinical reasoning are the necessary next steps to facilitate improvement of new graduate nurses' clinical reasoning skill.

Pursuing Improvement in Clinical Reasoning: Development of the Clinical Coaching Interactions Inventory.

BACKGROUND: Clinical coaching has been identified as a signature pedagogy in nursing education. Recent findings indicate that clinical coaching interactions in the clinical learning environment fail to engage students in the higher order thinking skills believed to promote clinical reasoning. METHOD: The Clinical Coaching Interactions Inventory (CCII) was based on evidence of supervisor questioning techniques, the Tanner clinical judgment model, Bloom's Taxonomy, and simulation evaluation tools. Content validity was established with expert assessment, student testing for clarity, and calculation of scale-content validity index/average (S-CVI/Ave). Reliability was established with Kuder-Richardson Formula 20 (KR-20). RESULTS: CVI (S-CVI/Ave) was .91, and KR-20 was .70. The CCII identified differences in clinical coaching behaviors in university faculty supervisors and staff nurse preceptor supervisors. CONCLUSION: The CCII advances the measurement of clinical coaching interactions from qualitative to quantitative. Ultimately, results from use of this inventory may facilitate the design of prelicensure clinical coaching strategies that promote the improvement of students' clinical reasoning skill. [J Nurs Educ. 2016;55(9):495-504.].

Is evidence guiding practice? Reported versus observed adherence to contact precautions: a pilot study.

BACKGROUND: Hospital-acquired infections are a major patient safety issue. We examined staff members' knowledge, attitudes, reported and observed adherence to guidelines, and perceptions of barriers to use of contact precautions. METHODS: A survey and nonparticipant observation study was used to examine knowledge, attitudes, perceptions, and actual behavior of staff on 3 medical/surgical units at a 600-bed Magnet-designated academic medical center (MDAMC) and a 110-bed community medical center (CMC) in the southeastern United States. RESULTS: Correct knowledge answers ranged from 75% (CMC) to 100% (MDAMC). CMC participants were less likely to perceive time as a barrier (5% vs 25%; P = .050); more MDAMC participants were motivated by supervisors' recognition (87% vs 33%; P = .001). No statistically significant differences existed between groups on reported behaviors. Upon observation, fewer CMC participants demonstrated 4 of 5 evidence-based contact precaution behaviors compared with MDMC participants (P < .001). Hand hygiene before glove application was similarly low at both sites. CONCLUSIONS: Despite a decade of focus on improving patient safety, low adherence to evidence-based practice guidelines for implementation of contact precautions remains. Ongoing efforts are needed both at the system and practitioner level to improve practice adherence.

Stool studies: tried, true, and new.

Much information can be obtained about a patient's gastrointestinal and overall nutritional status through stool samples. Important infectious processes and neoplastic processes are initially identified through diagnostic tests and screening of stool samples. Although in some arenas they are a source of embarrassment and distaste, the value of correctly obtained samples is unquestionable. Patient collaboration with a critical care nurse is integral to obtaining stool samples.