Increasing Clinical Judgment by Using Simulation in Associate of Science in Nursing Prepared Students

Nurse Educators are tasked with preparing graduate nurses (GN) to care for high acuity patients in the acute care setting. Graduate nurses will need to perform clinical skills safely and competently with appropriate clinical judgment and reasoning. Tanner (2006) defines clinical judgment as an “interpretation or conclusion about a patient’s needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response” (p.204). Graduate nurses rely on their personal knowledge from clinical experiences to help guide their assessment and interventions until new knowledge is gained from experience as a registered nurse. Depending on the students’ clinical assignments, these experiences can vary. Simulated clinical experiences (SCE) are shown to assist the students in developing clinical judgment while still in nursing school (Kim & Kim, 2015; Mahoney, Hancock, Iorianni-Cimbak, & Curley, 2013)

Using simulation, specifically High-fidelity simulation (HFS), has been researched to improve clinical judgment/reasoning in a safe, controlled environment (Lawrence, Messias, & Cason, 2018). HFS allows the student to learn from their mistakes and build clinical judgment skills safely and competently. By creating an SCE which encompasses scenarios of high acuity patient situations, the nursing student will be better equipped to provide safe interventions in the actual acute care setting. Using guidelines providing by the landmark NCSBN National Simulation Study (Hayden, Smiley, Alexander, Kardong-Edgren and Jeffries, 2014) and Simulation the International Nursing Association for Clinical Simulation and Learning (INACSL)Standards of Best Practice: Simulation^SM (INACSL, 2016) faculty in an associate degree program redesigned how simulation is used to prepare ASN students for clinical practice and increase the use of HFS throughout the ASN curriculum.

An increase in simulation throughout the ASN curriculum, with a focus of increased simulation in the student’s final semester, demonstrated increased scores on a standardized exam in areas that measure clinical judgment/reasoning. This nationally normed, standardized exam is given to students who have successfully completed all program requirements in the ASN program.

This ongoing study uses the aggregate results related to topic areas that address clinical judgment/reasoning the standardized exam. The standardized exam data were collected each semester, starting in Spring 2017 (N=144 students). An increase in the percentage of scores of items related to clinical judgment/reasoning was noted from 76.7% to 79.9%. Since Spring 2017, students have participated in more simulations throughout the ASN program, especially in their final semester. These results suggest that simulation helps to foster increased clinical judgment in the graduate nurse.

There are some additional variables in this study which should be acknowledged. For example, since spring 2017, the ASN curriculum has been adjusted to increase the number of NCLEX-style questions used in the didactic classroom in the ASN program. Also in Fall 2018, the use of the “flipped classroom”, as well as increased utilization of case studies, was implemented to attempt to enhance students’ knowledge of new material.

In conclusion, increasing simulation across the ASN program, with emphasis on the final semester, has suggested increased clinical judgment/reasoning scores on a standardized exam. However, further research needs to be conducted to evaluate if the increase has been from increased simulation, or from the teaching/learning activities used in the final of the ASN program.