Investigating the use of simulations in enhancing clinical judgement of students to practice as registered nurses

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On entry to the workforce nursing graduates are expected to respond to a range of clinical situations they may not have experienced during their program. The social aspects of practice such as professional behaviours are equally important for transitioning to the registered nurse role. Contemporary simulation strategies can provide students with experiences of how Registered Nurses would respond in a guaranteed range of patient care situations. The exponential rise of healthcare simulation over the last 15 years is reflected in the prolific number of publications about its use, participant evaluation and satisfaction, or improvements in skills technique. Few of these evaluations capture the impact of the simulation learning experiences beyond the immediate timeframe of the activity. Similarly, there is little research about how simulations may contribute to the ‘thinking’ aspects and holistic nature of professional practice and the pedagogy of simulation practices. This research explored the contribution of simulation for final year nursing students’ learning and clinical judgement capabilities; and the effect of simulations on students’ subsequent practice as new Registered Nurses in the year following graduation. Methods A multi-phase mixed methods approach was used in the research which comprised two studies. In Study 1, 108 final year nursing students responded to a pre- post-simulation survey. Opinion was sought about self-rated skills, knowledge and dimensions of practice prior to and following the simulation. The post-survey asked students to rate 11 components of the designated simulation to the application of clinical judgment. Study 2 comprised group interviews with nine students at degree completion, and 1:1 interviews during the first three months of registered nurse practice. Standard statistical analysis was applied to quantitative data and word clouds were created from the survey free text responses. Data from group and individual interviews produced a number of themes following iterative analyses. Students from three study streams were represented in both studies: 3-year program, 2-year accelerated graduate entry program; and 2-year accelerated enrolled nurse program. Key findings Prior to the simulation students felt least able about: caring for patients, their knowledge and clinical abilities. Following the simulation there was greater importance on the patient, communication and assessment. The top three simulation components which assisted students with clinical judgements were: post-simulation reflection, facilitated debriefing and guidance by the academic. At course completion students reported the simulations provided them with greater insight into the professional traits required for registered nurse practice as the activities presented opportunities to glue things together, draw on tacit knowledge and appreciate the holism of practice. Learning within simulation was situated, experiential and contextual but also elicited affective elements of learning, that is: emotions, behavioural norms and professional attitudes. Immediate effects on practice were greater attention to noticing patient cues and a willingness to inquire further and respond in meaningful ways. In the early months of practice, participants recalled the simulation experiences during sequent patient care situations of similar or contrasting contexts. Each new graduate nurse cited at least one instance where they were able to anticipate what may happen next in the patient care trajectory and responded by making judgements and decisions relative to the urgency of a situation. Clear connections were made between the simulations and their contributions to clinical practice. Conclusion Unlike other educational strategies, simulations provided unique learning opportunities for nursing students which contributed in meaningful ways as preparation for independent practice. In addition to improving confidence for practice, these new graduate nurses were able to make appropriate clinical judgements often within challenging situations, which influenced patient outcomes in positive ways.
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