Clinical judgment in new nurse graduates: identifying the gaps

Introduction

Educating the next generation of nurses presents multiple challenges and nursing faculty have had to face extensive changes in recent years. Lack of strong training specific to nursing education, gaps in the high school education system, burdens of moving to online teaching related to the pandemic, and significant faculty shortages are just a few of the many hurdles nurse educators must overcome [1, 2, 3, 4]. While not only striving to prepare graduates for the rigors of practice, nurse educators in many countries must also prepare students for the National Council Licensure Examination (NCLEX).

The National Council of State Boards of Nursing (NCSBN) administers the examination for licensure of registered nurses, attesting to the minimum safe practice of new nurse graduates who pass the exam. The NCLEX is offered at multiple sites around the world including (but not limited to) the United States, Canada, England, Mexico, Taiwan, and Turkey. Recently they have moved to focus the NCLEX on new nurse graduates’ clinical judgment. The NCSBN (2019) has defined clinical judgment as “the observed outcome of critical thinking and decision making. It is an iterative process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern and generate the best possible evidence-based solutions in order to deliver safe client care” (p. 1).

As new graduate nurses transition to practice, they face numerous challenges. Luo et al. [5] have described challenges that stem from high patient load, complicated interpersonal relationships, and a lack of nursing competence and confidence. In recent years, the Covid-19 pandemic prevented students from experiencing real-world clinical placements [6, 7]. This is where students would usually have the opportunity to develop interpersonal relationships and increase their competence, confidence, and clinical judgment. Due to a lack of real-world clinical placements and having to manage several students at once, nurse educators may have difficulty routinely addressing each of these areas in a limited clinical setting.

Since clinical judgment is imperative for safe clinical practice, the purpose of this study is to determine the current status of new nurse graduates’ clinical judgment upon transition to practice. The research question driving this study is: what is the current status of new nurse graduates’ clinical judgment levels when transitioning to practice? In answering this question, the groundwork may be laid for future exploration of appropriate educational interventions to better prepare undergraduate nursing students for practice.

Literature review

A problem encountered in reviewing the literature is the overlap in the use of the terms “competence” and “clinical judgment,” which are often used interchangeably and may confound the reported evidence. Mongale et al. [8] suggest that clinical judgment is the most appropriate concept for determining new nurse graduates’ ability to transition from academia to practice, which NCSBN (2019) corroborates. Regardless, the literature still informs the research question for this study.

Research has shown that new nurse graduates often lack clinical judgment skills which increases the risk that they will make errors in the care of patients (Klenke-Borgmann et al. 2021) [9, 8, 10]. The development of nursing clinical judgment is imperative for new nurse graduates to competently provide safe patient care. Others have reported that new nurse graduates are underprepared for the complexity of professional practice, are anxious and uncertain about their competence, and that entry-level competency is not adequate [11, 8, 12]. However, a recent mixed methods systematic review of new nurse graduates’ competence suggests they have good or adequate competence levels [13].

New nurse graduates’ clinical judgment has been questioned in several ways internationally. Self-assessment has shown that new nurse graduates’ competency level in Kenya is at advanced beginner for the majority of new nurse graduates following completion of an internship, and clinical judgment ability is inadequate [14]. A Korean study on the efficacy of simulation-based vs. peer-learning handover training for new nurse graduates was done to determine competence and clinical judgment [15]. A case study was used to determine whether the use of structured group problem-based learning activities implemented in a graduate nurse program for new nurse graduates in a hospital in Australia would build necessary clinical judgment [16–20]. These studies either stated or implied that new nurse graduates’ clinical judgment was lacking. Charette et al. [13] completed a mixed methods systematic review in Australia to look at new nurse graduates’ clinical competence. In contrast to the other studies, good or adequate clinical competence was suggested, but the term clinical competence is not equivalent to clinical judgment.

Billings [21] suggests that professional development educators use prompting questions in line with the NCSBN’s Clinical Judgment Model with newly graduated nurses during simulations, clinical case studies, and unfolding case studies throughout their orientation to develop their clinical judgment for safe practice. The use of simulation to enhance clinical judgment has been well explored in the literature. Simulations facilitate safe training opportunities, which allows students to be exposed to many different clinical scenarios and enables them to explain the thought process behind each decision [5]. Luo et al. [5] suggest that implementing different simulation types, such as virtual simulation, high fidelity simulation, and case studies can improve learning. It was determined in the study that those who participated in virtual simulations were shown to have better clinical judgment, while high fidelity simulations produced more confidence in newly graduated registered nurses [5]. Lawrence et al. [22] studied the impact of high fidelity simulations on BSN students and new nurse graduates. The results were similar to those found by Luo et al. [5] regarding the ability of high fidelity simulations to enhance the synthesis of knowledge when students are able to take on the full role of the nurse [22].

Montayre et al. [23] further defend including simulations within the curriculum to improve new graduate registered nurses’ clinical judgment. There is a need to strengthen the bioscience theory-practice gap early in a student’s education through the use of simulation experiences [23]. Similarly, Klenke-Borgmann et al. [24] state that high fidelity simulations significantly increased clinical judgment in pre-licensed new nurse graduates. Further, if a student uses multiple types of simulations, then they gain a better sense of clinical judgment compared with those who experience only one type of simulation [24]. Those who used simulation increased their clinical judgment in the following areas: noticing, interpreting, responding, and reflecting [24]. According to the literature, the use of simulation by new graduate registered nurses improves their clinical judgment without harming a real patient in the clinical setting. In addition to simulation, clinical coaching, which involves teaching, questioning, and immediate feedback by a faculty member or preceptor, is purported to facilitate development of clinical judgment [25]. Jessee [25] posits that this immediate feedback allows students to think of improvements which then enhances their clinical judgment.

Although the literature shows that overall clinical judgment is lacking in new graduate nurses, the particular areas of clinical judgment needing improvement have not been thoroughly explored. Further, the recommended nursing education interventions to date have been rather generalized with little input from experienced nurses precepting new nurse graduates. Our study intends to help fill this gap by addressing the dimensions of clinical judgment through surveying preceptors from our clinical partner facilities to inform needed curricular changes.

Theoretical framework

Tanner’s [26] model of clinical judgment is the basis of Lasater’s [27] clinical judgment rubric used in this study. Tanner [26] outlines four aspects of the process of clinical judgment, including noticing, interpreting, responding, and reflecting. Noticing is described as a “perceptual grasp of the situation at hand” [26, p. 208]. It involves the expectations of the situation as well as the nurse’s knowledge of the patient. Interpreting is described as development of “a sufficient understanding of the situation to respond” [26, p. 208]. Interpreting stems from noticing through triggering reasoning patterns that allow the nurse to decipher the meaning of the data and generate diagnostic hypotheses the nurse may respond to. Responding is deciding on and taking a “course of action deemed appropriate for the situation” [26, p. 208]. Reflecting includes attending to patient responses during the process of the action and reviewing the outcomes. This process depends on several factors, especially the nurse’s level of knowledge and experience.

Lasater [27] developed a rubric for faculty and preceptors to use in measuring students’ levels of competency in clinical judgment based on Tanner’s [26] model. She describes four levels of development for each of 11 dimensions of clinical judgment. The four levels progress from lowest to highest through beginning, developing, accomplished, and exemplary levels of clinical judgment in accordance with student development [27]. Although developed for use with nursing students, it has also been used effectively with new graduate and newly hired nurses [9, 8].

Methods

In this descriptive study the researchers distributed a survey to nurse preceptors to ascertain the current level of clinical judgment in new nurse graduates. Descriptive research is appropriate when the researcher desires information related to prevalence and characteristics of a phenomena of interest in a natural setting [28]. The survey was based on previous scholarship describing and evaluating clinical judgment frequently in educational settings, and this research provided the opportunity to further assess clinical judgment directly in the practice setting.

Results

Results show that six items had a score of three as the highest percentage, which included information seeking, prioritizing data, making sense of data, clear communication, well-planned intervention/flexibility, and being skillful. Recognizing deviations from expected patterns scored two and three approximately equally. A score of two was shown for focused observation and calm, confident manner. The frequencies, as percentages, for each LCJR item and the mean scores and standard deviation for each item are shown in Table 2. Cronbach’s alpha for the tool in this study was 0.913.

Significant data were gathered through responses to the open-ended questions. Data were initially reviewed by the researchers in entirety and descriptive terms for key topics were developed. After further review data were organized into matrix displays based on descriptive terms to identify overall thematic categories [30]. Classification of the data resulted in three thematic categories: (a) Recognizing connections through real world learning; (b) Communicating with confidence, (c) Prioritizing care based on changes.

Discussion

The author of the LCJR suggested that the goal for new nurse graduates would be Accomplished level or level three (K. Lasater, personal communication, March 12, 2021). However, our results show only six items had a score of three as the highest percentage, including information seeking, prioritizing data, making sense of data, clear communication, well-planned intervention/flexibility, and being skillful.

Based upon the findings of this study, new nurse graduates are challenged by the amount of data they face in the clinical setting and have difficulties identifying key information. In a recent study, Mongale and colleagues (2018) found that new nurse graduates were only able to focus on certain aspects of the patient situation and missed other important information. Shinnick [31] found that new nurse graduates were able to identify key assessment parameters in complex patient situations but required significantly more time to recognize the issue.

Mongale et al. [8] noted that nurse leaders report new nurse graduates are not practice ready. The gap between practice and education has been noted by experts in the field and is expected to continue into the future unless nursing education transforms [32]. Results from this study indicate that new graduate nurses are more proficient at certain skills such as seeking information, but need more preparation related to areas such as calm, confident responses. Prelicensure nursing education models have often followed the tradition of continuing to add information as the science progresses without considering how this might burden the curriculum [32]. Many students are overwhelmed by the amount of data they are presented with in their nursing education, and this may continue into their early practice. Findings from this study may help educators find specific areas to focus on in classroom and clinical activities to enhance clinical judgment. This teaching for students “to gain a sense of salience, which is when a practitioner can discern what is more or less important in a clinical situation” [32, p. 25] addresses clinical judgment and may help nurse educators identify areas of practice that need more attention in the curriculum, while decreasing the attention on areas where new nurse graduates typically have a solid grasp.

Implications for an international audience

As previously mentioned, the NCLEX is used as a tool in many countries to assess minimum safe levels of nursing competency upon entry to practice. In recent years clinical judgment has become the major focus of the exam and nurse educators, internationally, are in a prime position to prepare their students both for this rigorous testing and the challenges of entry to practice. New graduate nurses are the last line of defense for many vulnerable patients, and nurse educators can ensure safety by striving to provide instruction that enhances students’ abilities to make sound decisions and identify key issues.

Lower income countries face some of the highest burdens to health care systems and well-educated nurses are expected to help lead the way into a more promising future. In a qualitative study in East Africa, findings supported the need for nurses to be agile and confident decision makers (Brownie et al. 2022). If new nurse graduates are struggling to identify the most important information in a clinical situation, this may inhibit that ability. Further recommendations from this study also highlight the importance of stakeholders when designing educational interventions (Brownie et al. 2022). This study, utilizing the input of practicing nurses in the area, demonstrates how stakeholders can be engaged to improve the education process.

Conclusions

Results from this study indicate that new nurse graduates could benefit from more targeted education related to focused observations, and, calm, confidence manner dimensions. A surprising finding is that new nurse graduates were rated as competent overall in skills. Based on previous anecdotal evidence this was expected to be a deficiency. Nurse educators can use evidence-based targeted educational interventions such as simulation or case studies to further develop students in preparation for the complexities of practice and avoid information overload. Findings from this study may present the opportunity to create more focused offerings and measure outcomes based on further adaptions of the clinical judgment rubric, evaluation by practice partners, and/or NCLEX scores. Further explorations of education and practice partnerships could lead to updated curriculum and new nurse graduates that are better prepared for the challenges of clinical practice.