All prelicensure baccalaureate nursing students are expected to graduate with baseline knowledge and clinical judgment skills that will allow them to provide safe and competent patient care to individuals across the lifespan. Research has shown that clinical judgment in new graduates is at an all-time low. There is an abundance of research on how to cultivate clinical judgment skills in both the didactic and simulations settings; however, very few studies have been conducted exploring how to assess and build clinical judgment skills in students in the clinical setting. A pilot study, followed by a quasi-experimental study, and a related correlational study, were performed to explore how clinical judgment can be assessed and enhanced in the prelicensure baccalaureate clinical setting.
These studies included outcome variables of knowledge and self-confidence. The studies were guided by Kolb’s Experiential Learning Theory as well as Tanner’s Clinical Judgment Model.The pilot study used an adapted form of the focus group method and aimed to determine the best way to apply the structured debriefing method of Debriefing for Meaningful Learning (DML) in the clinical setting. The pilot study included clinical faculty (N = 4) in a baccalaureate nursing program at a small college in Upstate N.Y. The study began with training on DML, followed by an asynchronous pre implementation survey where participants provided answers to interviewer questions via Google forms. Next the study involved 3 weeks of implementing DML with clinical groups in the clinical setting and concluded with a post implementation synchronous focus group that met via Zoom©. The results of the pilot study
led to a few adaptations in the DML process including the creation of a faculty script, a student guide, a new concept map, and a change to when students were expected to complete the concept map during their clinical day.
The quasi-experimental study took place at the same college and included participants (N = 62) in the course NSG 323 – Concepts II in both the Spring 2023 and Fall 2023 semesters. The intervention was DML and took place during three clinical experiences (one per week) in the first half of the semester. Participants and clinical faculty completed pretest measures in the week prior to beginning their clinical experiences. Pretest clinical judgment was measured during a simulation scenario by the participants’ clinical faculty using the Lasater Clinical Judgment Rubric (LCJR). The LCJR is a 4-point Likert-type scale measuring 11 dimensions of clinical judgment under four subscales of noticing, interpreting, responding, and reflecting. Self- confidence was measured using a revision of the NLN Student Self-Confidence subscale of the NLN Student Satisfaction and Self-Confidence in Learning instrument. The revised scale is an 11-item Likert-type scale.
The revision involved changing items that include the word “simulation” to the word “clinical experience.” Knowledge was measured, posttest only, using scores on the second Unit Exam of the course. A mixed 2 x 2 Analysis of Variance (ANOVA) followed by simple main effects t tests were used to analyze the clinical judgment and self- confidence data, and independent samples t tests was used to analyze exam scores. Results for clinical judgment did not reveal a significant interaction between groups and time (F (1, 60) = .21, p = .652). There was a statistically significant main effect found for group on LCJR scores overall (F (1, 60) = 7.65, p = .008). Both pretest and posttest mean scores for the LCJR were lower in the intervention group (M = 22.54 and M = 25.88 respectively) than in the control group (M = 27.75 and M = 30.33 respectively).
The results for self-confidence did not reveal any significant interaction between groups and time (F (1, 59) = 1.44, p = .235). The mean scores for the posttest were higher in the intervention group (M = 42.65) than in the control group (M = 40.83). Results also showed that while self-confidence scores from pretest to posttest for the intervention group increased, the scores from pretest to posttest for the control group decreased; however, the differences in groups did not reach statistical significance (F (1, 60) = .45, p = .504). An independent samples t test showed no significant difference in Unit II exam scores, measuring knowledge, between groups (p = .451, d = .20).
A correlational study was completed exploring the relationships between clinical judgment, knowledge, and self-confidence using the data obtained in the quasi-experimental study. This study also explored the differences between groups for each correlation, and whether having prior health care experience impacted each outcome variable. Results showed no statistically significant correlation between pretest clinical judgment and pretest self-confidence scores (r = .09, p = .502), nor between posttest clinical judgment and self-confidence scores (r = -.22, p = .085) for the entire sample.
However, there was a significant negative relationship between posttest self-confidence and clinical judgment in the control group (r = -.36, p = .034). The differences between groups in the pretest correlations of clinical judgment to self-confidence (zobs = .298, p = .764) and in the posttest correlations of clinical judgment to self-confidence (zobs = -1.61, p = .107) were not significant. There was also no statistically significant relationship revealed between both the pretest (r = -.10, p = .439) and posttest (r = -.18, p = .163) self-confidence scores and knowledge, as measured by Unit II exam scores for the entire sample, as well as within groups. The difference in correlations between groups on both the pretest self-confidence scores and exam scores (zobs = -1.29, p = .197) and posttest self-confidence scores and exam scores (zobs = -.643, p = .522) were not statistically significant.
However, both pretest (r = .36, p = .004) and posttest (r = .39, p = .002) clinical judgment scores and posttest- only exam scores were revealed to have a positive statistically significant correlation for the entire sample, as well as in the intervention group only (r = .59, p = .002 and r = .632, p < .001 respectively). The difference in correlations between pretest clinical judgment and knowledge was significant (zobs = -2.29, p = .023). The correlation between posttest clinical judgment scores and exam scores for control group was .084, and .632 for the experimental group. The difference in correlations between posttest and knowledge was ~ .55, also statistically significant (zobs = -2.45, p = .0151).
There is a long-held understanding in nursing education that the teaching-learning strategies in the clinical environment need to be evaluated and improved. While not revealed to have a statistically significant effect in this initial study, the use of structured debriefing methods should still be further explored in the clinical setting to determine whether the process can be an acceptable pedagogical approach to improve knowledge and clinical judgment in the clinical setting. The moderate positive statistically significant relationship between clinical judgment and knowledge found in this study aligns with Tanner’s (2006) theory that the development of both knowledge and clinical judgment is a related and cyclical process where both should be emphasized. The inverse relationship found between self-confidence and clinical judgment/knowledge, while not statistically significant in this study, suggests that students will benefit from honest and constructive feedback on their performance to accurately evaluate themselves and their ability to perform in the clinical setting.
| Identifer | oai:union.ndltd.org:columbia.edu/oai:academiccommons.columbia.edu:10.7916/svnh-3n22 |
| Date | January 2024 |
| Creators | Dolen, Erin R. |
| Source Sets | Columbia University |
| Language | English |
| Detected Language | English |
| Type | Theses |
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