Exploration of Two Methodologies for Measuring Clinical Judgment in Baccalaureate Nursing Students.

Abstract

Introduction: Senior nursing students need a requisite level of preparedness to safely care for an acutely ill, complex patient once they graduate and become independent clinicians. This level of preparedness may be evaluated by measuring clinical judgment (CJ) with the Lasater Clinical Judgment Rubric (LCJR). The LCJR contains 11 indicators that represent the actions and behaviors necessary for demonstrating CJ. Two methods of simulation, high fidelity patient simulation (HFPS) and objective structured clinical examination (OSCE), replicate the healthcare environment so students may safely demonstrate clinical skills without harming an actual patient. The purposes of this study were to 1) explore the use of the LCJR in the OSCE setting, and 2) elicit and compare the number of LCJR indicators that occur in the HFPS and OSCE settings for senior baccalaureate nursing students. Two research questions were explored: 1) comparing the representation of indicators between the OSCE and a single HFPS and question 2) comparing the representation of indicators between the OSCE and two HFPSs. Methods: This study used a two group, randomized crossover design with 23 senior nursing students in their last semester of a Bachelor of Science in Nursing program (n = 11; n = 12). Each participant performed patient care during two HFPS scenarios and 12 OSCE stations, followed by a written debriefing. Clinical performances were video recorded for each participant. CJ was evaluated by the reviewing the video recordings and counting the number of times an LCJR indicator occurred during the HFPS and OSCE settings. Counts for each indicator in each setting were established for the OSCE by adding indicator counts for each and for the HFPS by adding each indicator for the two scenarios. Comparisons of the OSCE to individual HFPSs as well as the combined HFPS means were performed using paired t-tests with an alpha value of 0.05. Results: The mean number of times that the LCJR indicators occurred in the OSCE setting was significantly higher (p < 0.05) than in either individual HFPS setting, indicating that the OSCE setting provided more opportunities for measuring CJ than a single HFPS setting. When comparing the OSCE to the combined HFPSs setting the mean counts of LCJR Indicators 3, 4, 5, 7, and 9 were higher in the OSCE, while counts for LCJR Indicators 2, 6, and 8 were higher in the combined HFPS settings. Indicators 3, 5, and 7 count means were more than five counts higher, indicating a likely impact on the accuracy of CJ scores regarding those indicators and a more favorable environment to measure those indicators within the OSCE setting. Participants reflected on their simulation experiences by answering written questions during the debriefing sessions to measure Indicators 10 and 11. Opportunities to measure Indicator 10 were similar between the two settings, while Indicator 11 occurred more in the students’ written OSCE debriefing than in HFPS debriefing. No variability existed with Indicators 10 and 11, thus statistical significance could not be determined. Conclusions: The overall higher mean count of LCJR opportunities in the OSCE setting suggests that OSCE provides a comparable number opportunities to measure CJ of senior nursing students. While previous research has validated the use of the LCJR tool in the HFPS setting, the results of this study suggest that the LCJR may be used in the OSCE setting and be similarly suitable. The OSCE uses less faculty resources than HFPS and thus may be a more cost-effective mode for evaluating CJ. However, additional research is needed to establish the validity and feasibility of using the LCJR tool in the OSCE setting to measure CJ in senior nursing students prior to graduation.