In my experience as a nurse educator, students would lament that, although they did well on my pathophysiology exams and understood the content in the safety of a classroom, they felt completely unprepared in the clinical setting when caring for real patients. I would reassure these students that the ability to put the pieces together is called clinical judgment, which comes with time and experience. Eventually, after hearing the same story from many different students, time and time again, I began to ask myself this question: "Yes, clinical judgment development does come naturally with time and experience, but what can I do as a nurse educator to help speed up that process for my students and make it less painful?"
Despite the identified need for nurses to develop clinical reasoning skills (Miraglia & Asselin, 2015), a mere 35 percent of graduate nurses meet entry-level expectations for clinical judgment. Likewise, only 13 percent of preceptors believe that newly hired RNs are able to set appropriate patient priorities (del Bueno, 2005; Lasater, Nielsen, Stock, & Ostrogorsky, 2015). Although well versed in content, the majority of new graduate nurses are unable, or have considerable difficulty, to translate knowledge and theory into practice (del Bueno, 2005). In other words, there is a major disconnect between classroom learning and application of that learning in practice settings.
STRATEGY FOR CLINICAL JUDGMENT DEVELOPMENT
A review of the literature found significant increases in clinical judgment in nursing students after high-fidelity simulation-based experiences (HFSBEs), especially after multiple exposures (Shin, Ma, Park, Ji, & Kim, 2015; Yuan, Williams, & Man, 2014). These results support that the multifaceted nature of high-fidelity simulation provides a rich, contextual learning environment that leads to better transfer of learning, higher motivation, confidence, and skill competency among nursing students (Blum, Borglund, & Parcells, 2010; Fawaz & Hamdan-Mansour, 2016; Kirkman, 2013; Shinnick & Woo, 2013). Most of the evidence focuses on the use of HFSBE in the clinical simulation laboratory.
Benner, Sutphen, Leonard, and Day (2010) called for nursing education to move away from the sharp demarcation between clinical and classroom teaching and recommended an integration of these two venues for learning. Thus, I decided to utilize HFSBE as a teaching strategy in my pathophysiology classroom with third-year nursing students in an attempt to bridge this discord and facilitate clinical judgment development in my undergraduate baccalaureate students. The goal was to create a rich, contextual environment in which students could experience the interrelationship between classroom-taught knowledge and real-world implementation.
This HFSBE was guided by Tanner's (2006) integrative model of clinical judgment, which explains how nurses (and nursing students) think. I wanted an environment that encouraged my students to think about tasks directly related to the congestive heart failure concepts that had recently been covered via lecture format in the course.
IMPLEMENTATION
On the day before a regularly scheduled two-hour class period, two student volunteers participated in a video-recorded, 20-minute hands-on implementation of a high-fidelity simulation scenario involving a patient with congestive heart failure in the simulation laboratory. The students were informed of the objectives of the experience: 1) formulate an appropriate plan of care given the patient's physical presentation and 2) identify appropriate nursing interventions. They were encouraged to do their best as it would not matter (in terms of their grade in the course) if the objectives were not completely met. Rather, any unmet objectives would be a source of discussion and learning in debriefing sessions.
The scenario involved a simulated 68-year-old male patient admitted through the emergency department two days previously with a new diagnosis of congestive heart failure, experiencing exacerbation of symptoms. The simulated patient was currently being treated for flash pulmonary edema. The scenario adhered to the International Nursing Association for Clinical Simulation and Nursing's (2016) Standards of Best Practice: SimulationSM Simulation Design. When the 20-minute HFSBE was complete, a 10-minute debriefing session, guided by the Lasater clinical judgment rubric (Lasater, 2007), was conducted between the faculty member and the student volunteers.
The recording was viewed by all 104 students in the course (including the volunteers) during the next regularly scheduled class. Following the viewing, the class divided into self-selected small groups (seven to eight students) to discuss and debrief the video for approximately 15 minutes. The faculty member roamed the room, facilitating discussion and reflection among the groups. The entire class then reconvened for a 15-minute, large-group debriefing session led by the faculty member, guided by the Lasater rubric (2007).
Specifically, the students were asked to reflect on the performance of the volunteers using the concepts of noticing, interpreting, responding, and reflecting (Lasater, 2007). For the concept of noticing, the groups discussed questions such as, "Did the student volunteers perform a focused observation, recognize deviations from expected patterns and seek more information?" For interpreting, questions included "Did the student volunteers prioritize data appropriately and make sense of the data?" For responding, questions included "Did the student volunteers portray a calm/confident manner, use clear communication, have a well-planned intervention and exhibit skillfulness?" For reflecting, questions included "Did the student volunteers evaluate and analyze their personal clinical performance and demonstrate a commitment to ongoing improvement?"
STUDENT RESPONSES
Following the HFSBE, students responded to the following open-ended question via paper/pencil survey: Do you feel that this classroom activity has helped bridge the gap between classroom learning and clinical judgment in the clinical setting? Some responses were brief yet constructive, such as, "Just coming up with any way to visually integrate patho[physiology] in the clinical setting is the best form of teaching yet" and "I do believe this simulation really helps students see how all our classroom learning correlates with [the] clinical setting."
More specific comments that captured the essence of the purpose of the teaching strategy included statements such as, "It allowed for me to challenge myself and put the pieces together, without being told the answer[horizontal ellipsis]. It put my knowledge to the test in the moment and helped me feel more prepared for what the clinical setting will look like with these certain heart situations," and "The bottom line is that people are not textbooks, so for me it was helpful to see how bits and pieces of what we learn in class work together in the clinical setting and how all of our classes overlap with each other."
FACULTY RESPONSE AND LESSONS LEARNED
Based on students' feedback, this classroom-based, prerecorded HFSBE learning activity is one approach that may have implications that bridge the classroom-clinical gap and encourage students to critically think beyond the confines of classroom memorization. It allows students to apply newly acquired classroom knowledge to a real-world situation within an integrated, safe, and controlled learning environment. Given the overall positive response and the desire by several students to have more than one such activity within the course, I plan to use this strategy more frequently going forward.
Based on the initial experience, I will consider making some minor modifications. For example, although most students in the self-selected small groups appeared to be quite engaged (lively discussion, active listening), it would be interesting to assign students to groups and compare level of engagement. It would also be interesting to change the number of students in each small group to see if that makes a difference in engagement. It is possible that having more than one facilitator would increase the level of engagement and clinical judgment development among students.
Research to support this teaching and learning strategy is needed. As research has shown that three exposures to high-fidelity simulation are needed before gains in clinical judgment development are statistically significant (Yuan et al., 2014), research should be conducted that incorporates a minimum of three HFSBE activities into a traditional classroom setting over a semester. Furthermore, it would be desirable to evaluate results with a greater number of pathophysiology courses at additional schools of nursing. Quantitative research must be conducted to study the causal relationship between HFSBE learning activities in the classroom setting and clinical judgment development.
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