Nurse educators work to develop critical thinking skills to enhance clinical judgement through a variety of means such as simulation (Kardong-Edgren, 2012, Chen, Chen, Lee, Cheng,& Yeh, 2017), role-playing (Juarez et al, 2006) ), portfolios (McMullan, 2008) and clinical placements (Woodley, 2013). Students must learn to develop self-awareness of their own clinical reasoning and judgement skills (Akerjordet & Severinsson, 2007) to continue their professional learning as novice and practicing nurses. Walsh and Seldomridge (2006) emphasize that students need to learn specific types of thinking relevant to novice practice; such as problem solving, decision making and diagnostic reasoning in health care situations. Nursing students need opportunities to act as detectives in order to develop clinical reasoning and judgment, learn how to act in given situations, set priorities, respond to changes in a patient's condition, and attend to evidence-based rationales to guide practice (Benner et al., 2010). Simulation with Human Simulation Manikins (HSM) permits faculty to expose students to complicated yet safe patient care situations that permit development of and practice of these type of reasoning skills (Samei & Lasater, 2016). Indeed, Chee (2014) observed that education using deliberate simulation experiences developed specific clinical skills more effectively than did traditional clinical experiences.
Lasater’s Clinical Judgment Rubric (LCJR, 2007) was used in a senior baccalaureate simulation course as a scaffolding for development of clinical judgement behaviors and practices, and to measure awareness of behavioral deficits. The LCJR uses the nursing process framework which provided a logical structural format already familiar to students. The LCJR provided direction for assessing clinical judgment for both faculty and students in a new simulation course.
The primary research hypothesis theorized that through weekly reflection using the LCJR, students’ awareness of and incorporation of critical thinking behaviors would improve their movement across a continuum of novice towards exemplary behaviors.
Secondly, we hypothesized that this increased self-awareness of critical thinking behaviors would lead to accurate student self-evaluation of simulation lab participation. Therefore, faculty member’s evaluations and student self-evaluations using the LCJR should closely correlate. IRB and LCJR author permissions were granted.
Participants (N=57), traditional undergraduate college students in their senior year, were assessed regarding use of the LCJR in three different ways. Two methods were quantitative. A quasi-experimental design using repeated-measures test compared students’ scores at two different points during the 14 week semester. And a quasi-experimental design compared between group comparisons of faculty and student final averaged LCJR scoring. Qualitative student focus group surveys provided additional data to better triangulate particular strengths or concerns related to use of the LCJR.
In two-tailed t-test analysis of LCJR scores, students’ self-evaluation scores (M=2.675, SD=0.2491) compared with faculty evaluation scores (M=3.12, SD=0.3175), with a p-value of 0.0389 demonstrated no significant difference between the means using a 95% confidence interval. It was found that students across all twelve sections consistently graded themselves lower than faculty at the interventional dimension, but graded themselves slightly higher than faculty at the diagnosing dimension. This correlates with what Benner, Tanner and Chesla (2009) describe as a tendency of novice nurses to focus on mastering skills versus developing a “big picture” perspective. However, unlike Fenske, Harris, Aebersold and Hartman (2013), overall scores were similar between students and faculty with these traditional, inexperienced students. Faculty assessment of students demonstrated movement across the continuum of novice towards exemplary behaviors over a 14 week course.
The LCJR provided direction for assessing clinical judgment for both faculty and students in a high acuity 14 week simulation course. It provided consistent descriptors in debriefing feedback and promoted an objective measure of clinical evaluation (Lasater, 2007). Though orientation to LCJR use proved cumbersome initially, the LCJR guided development of clinical judgement behaviors and reflection for students in a consistent and deliberate manner.