An Inquiry into the Undergraduate Nursing Students' Development of Clinical Judgment

Nurse educators strive to produce new graduate nurses with the competencies of the advanced beginner (Benner, Sutphen, Leonard & Day, 2010). Yet there is widespread recognition that recent graduates initially enter practice with limited preparation for providing safe nursing care to complex patients (Welding, 2011). Sound clinical judgment is an important aspect of providing safe care. Clinical judgment involves the nurse’s grasp of patient needs and the decision to take action (Tanner, 2006).  The nurse with sound clinical judgment skills views the patient holistically, readily grasps salient patient needs, and anticipates potential changes in the patient’s condition in a timely manner (Hart, Maguire, Brennan, Long, Robley & Brooks; 2014).  Inadequate clinical judgment skills may contribute to the nurse’s lack of self-confidence, leading to anxiety and hesitancy to communicate with other members of the health care team. Inadequate clinical judgment skills, including a failure to recognize crisis situations early enough to intervene, may contribute to adverse patient outcomes.   

Better understanding the processes involved in the development of clinical judgment as an integral component of expert nursing practice is foundational to the implementation of effective teaching/learning approaches. To effectively teach clinical judgment, nurse educators need a clear understanding of the skills and processes involved. Tanner (2006) identified four aspects of clinical judgment: noticing, interpreting, responding and reflection.  Each of these aspects presents opportunities for improvement of clinical judgment skills.  Nurse educators have endeavored to take advantage of these learning opportunities through the use of numerous pedagogies.  Among more recent methods are concept maps, high fidelity simulation and guided reflection. 

Concept maps are visual representations of relationships between and among various aspects of patient information and care (Wilgis & McConnell, 2008).  Gerdeman, Lux & Jacko (2013) studied students in their junior year of a BSN program using concept maps in combination with a self-evaluation rubric based on Tanner’s four aspects of clinical judgment.  They reported that students found concept maps helpful in identifying areas of knowledge deficit, developing priorities, connecting knowledge to practice and developing a more holistic view of the patient.  Each of these outcomes was in turn thought to enhance clinical judgment development. In both traditional clinical post-conferences and structured debriefings in simulation laboratories, guided reflection is a widely used teaching/learning approach in clinical nursing education.

According to Tanner (2006), reflection, the fourth aspect of clinical judgment, encompasses both reflection in action and reflection on action.  Reflection in action enables the nurse to notice patient responses and adapt their interventions while reflection on action enables the nurse to develop expertise and knowledge for future use.  For practicing nurses this reflection often occurs when there has been a breakdown in clinical judgment (Tanner, 2006), yet reflection on action is essential for the development of nursing expertise.  In both traditional clinical post-conferences and structured debriefings in simulation laboratories, guided reflection is a widely used teaching/learning approach in clinical nursing education. In their investigation of reflective debriefing following simulation, Lavoie, Pepin & Boyer (2013) found that novice nurses reported improved prioritization and better understanding of how they arrived at decisions regarding patient care following reflective debriefing of a high fidelity simulation experience. Faculty can encourage reflection on the part of students by modeling this behavior themselves and guiding students by questioning them both individually and as a group in post clinical post conferences or simulation debriefings

High fidelity simulation is a means of education that is becoming increasingly popular, with many nursing programs investing time and money in space, simulators and personnel (Lasater, 2007).  Static manikins are a standard means of technical skill development for beginning nursing students. Since the early 2000s, the use of high fidelity simulation has grown, along with the notion that this clinical teaching method may have a number of advantages. These advantages include: an increase in students’ confidence, opportunity for faculty to validate students’ knowledge and skills, and enhanced acquisition of clinical judgment in a safe environment for students (Lasater, 2007).  Various researchers have reported improved clinical judgment and increased student confidence as the result of use of high fidelity simulation (Kirkman, 2013; Lasater, 2007; Rhoden & Curran, 2005). 

Concept mapping, structured reflection, and high fidelity simulation are examples of teaching strategies aimed at enhancing the development of clinical judgment in nursing students.  All of these methods of enhancing clinical judgment show promise but there remain some additional areas to be addressed to further our understanding of this complex phenomenon. There are several gaps in the current literature. Foremost, there is little evidence about how simulated clinical judgment activities transfer to the clinical practice arena; the trajectory and persistence of gains in clinical judgment skills as nursing students graduate and transition into nursing practice, and the continued practice of reflection among practicing nurses.  There is also a lack of information about how various pedagogies can be combined most effectively to enhance clinical judgment development in nursing students.

Most educational interventions involving nursing students are evaluated soon after they are implemented, while students are still in their educational program.  There is a lack of research on translation to the clinical area for student nurses participating in clinical education, and there is little information regarding the clinical judgment abilities of practicing nurses who were educated using various pedagogies.  High fidelity simulation in particular is complex.  There are large areas unexplored ranging from scenario design to methods of enacting simulations to best practices in debriefing.  In addition, a single pedagogy is rarely used in isolation.  Exploration of how these methods are most effectively combined would be of great interest to educators.  Potential questions for future research include: 1. What is the trajectory and longevity of gains in clinical judgment as students transition into practice? 2. To what degree are students who are observed to demonstrate improved clinical judgment in the simulation environment also observed to demonstrate improved clinical judgment in the clinical setting as students? 3. What experiences do identified expert nurses identify as major contributors to their development of expertise? 4. What are best practices for faculty to encourage reflection as a lifelong habit?

Building on the existing research in the areas of nursing expertise and clinical judgment, there is still a need to further research and understanding of best practices regarding the teaching and learning of clinical judgment. Such research would not only enhance nursing practice but contribute to improved patient care.