Nurses care for sick, frail patients and must make critical decisions about the utilization of life-saving technologies. This responsibility is thrust upon new nurses immediately after graduation; therefore, it is essential for new nurses to have the ability "to think like a nurse" in their first professional position (Tanner, 2006). Nurse educators are faced with the task of certifying students as competent in the clinical setting, a task more complex than the evaluation of theory content as assessed by exams, papers, and projects. Although clinical performance may be measured by assessing psychomotor skills, the assessment of knowledge, preparation, judgment, and situational response is perhaps more essential (Walsh & Seldomridge, 2005).

Clinical judgment, specific to each situation and patient (Tanner, 2006), is the process employed to arrive at an understanding of the problems, issues, or concerns of patients; to focus on relevant information; and to respond in an appropriate and timely manner (Benner, Sutphen, Leonard, & Day, 2010). The new graduate nurse's ability to provide safe, high quality care can be contingent upon the ability to think, reason, and judge. To provide experience and increase the ability of novice graduates to engage in critical decision-making, nursing programs integrate the use of human patient simulation (HPS) throughout the nursing curriculum.

Research supports improved critical thinking skills and the development of clinical judgment as benefits of embracing the use of HPS (Blum, Borglund, & Parcells, 2010; Jensen, 2013; Lasater, 2011). This quantitative study utilized the Lasater Clinical Judgment Rubric (LCJR) to investigate the relationship between the student's self-assessment of clinical judgment skills and faculty's assessment of clinical judgment skills during an HPS acute care, adult medical scenario.

METHOD

Design and Sample

This study was approved by the university's institutional review board and conducted using a convenience sample of 94 junior-level baccalaureate nursing students; all students signed consent forms. Students participated in the HPS experience as dyads. Prior to the simulation experience, they accessed the LCJR and scoring sheet. All students were evaluated by one evaluator, and each student completed the LCJR; subsequently, scores completed by the evaluator and the student were compared. Once all data had been collected and paired, the investigator deidentified the data to prevent any breach of confidentiality.

Data Collection and Analysis

The LCJR measures clinical judgment in a simulated learning environment (Blum et al., 2010; Dillard et al., 2009; Lasater, 2011). It was developed from Tanner's Clinical Judgment Model, which is divided into four levels of clinical judgment (noticing, interpreting, responding, and reflecting). Previous research supports its reliability and validity. For example, Adamson, Gubrud, Sideras, and Lasater (2012) found an intraclass correlation of .89 among nurse educators across several settings. The same study found support for the criterion validity of the LCJR, in which the instrument predicted known differences between junior and senior nursing students.

The LCJR categorizes four measurement options (beginning, developed, accomplished, exemplary) and further assesses the subcategories of each level of clinical judgment. Consequently, it includes a total of 11 dimensions of clinical judgment, which are scored on a 4-point Likert-type scale. Scores are totaled to obtain an overall clinical judgment competency level for each participant. The minimum clinical judgment score possible is 11 (beginning competency level), with a possible maximum of 44 (exemplary competency level).

The evaluator, who had previous experience with the LCJR, was not a course faculty member. The evaluator entered scores on the LCJR as students completed the HPS experience; upon completion of the experience, students completed their self-assessment using the same instrument. The use of a sole evaluator eliminated the issue of interrater reliability.

Data were analyzed using SPSS version 19. The Pearson product-moment correlation (r) statistic was used to determine the relationship between faculty and student scores on the LCJR.

RESULTS

The sample (n = 94) consisted of 90 female students and 4 male students. Most students (n = 72, 77 percent) were between the ages of 18 and 21; 15 were 22-25 years of age, 6 were 26-30 year of age, and 1 was older than 30. The sample was largely Caucasian (n = 83, 88 percent); 6 were African American, 1 was Hispanic, and 4 did not indicate ethnicity.

Students' self-reported total scores on the LCJR were higher (M = 33.48, SD = 3.719, range 27-43) than the evaluator's scores (M = 31.19, SD = 3.220, range 24-38). The positive correlation (r = .314), although not strong, between the evaluator and student scores was significant (p = .030). The Cronbach's alpha estimate of reliability for this study was .82.

DISCUSSION

Findings from this study support the use of the LCJR as an instrument to use in conjunction with HPS to evaluate nursing students' clinical judgment skills and quantify competency levels. The positive correlation was consistent with findings that students' perceptions of clinical competency are consistent with those assessed by faculty (Cato, Lasater, & Peeples, 2009). Supporting findings by Jensen (2013), this study found that the students' self-assessment mean score was higher than the evaluator's mean score, indicating that students felt they were more accomplished than the evaluator did.

Although students rated themselves in a similar range when compared to faculty, their scores were higher overall. It is possible that overconfidence based on inflated self-assessment is detrimental to inexperienced nurses and may result in unsafe patient care (Baxter & Norman, 2011). Therefore, direct observation and evaluation of student clinical judgment skills and competency level by nurse educators is crucial in providing the feedback needed to produce competent nurses.

Self-assessment is an important part of nursing education and should be used with other objective evaluations to provide a balanced view of student clinical performance (Jensen, 2013). The findings of this study indicate that the LCJR may be an effective self-assessment tool to help students progress from thinking like a student toward the goal of thinking like a nurse.

The findings support the use of the LCJR by educators to quantify clinical performance and help identify areas for student improvement. The LCJR can help students self-reflect about their clinical judgment. By using the LCJR, faculty and students are able to evaluate performance using a common language to foster feedback and discussion.

This study was completed at one site utilizing a convenience sample with a homogeneous group of students, limiting the ability to generalize findings. Replication with a larger sample and/or multiple sites should produce a more diverse subject pool and increase the generalizability of the results.

CONCLUSION

The use of HPS is becoming more commonplace in nursing education. Research reinforces that HPS is an innovative teaching method that assists students with the development of clinical judgment skills (Blum et al., 2010; Jensen, 2013; Lasater, 2011). The finding of a positive relationship between student and evaluator's assessments of clinical judgment skills supports the feasibility of utilizing HPS to foster development of clinical judgment and lends credibility to use the LCJR as an evaluation tool. These results add to the body of knowledge about strategies to minimize the theory-practice gap, which new graduates experience when working for the first time in a new professional role.

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