The Impact of Virtual Simulation on Clinical Judgment Development in Undergraduate Nursing Students: A Pilot Study

Abstract

Background: Healthcare today is more complex than ever, with patients arriving at hospitals severely ill, often with multiple comorbidities. As patient care acuity rises, so does the need for nurses who can make safe and effective clinical judgments while ensuring quality care. Clinical judgment involves recognizing important aspects of a patient's condition, interpreting them, and responding appropriately. For years, clinical judgment and decision-making have been critical in prelicensure education, and recent research has focused on measuring these skills with psychometric precision using case studies and innovative item types on the licensure exam determining whether new graduate nurses are prepared for the complexity of patient care.

Method: This study utilized David Kolb’s Experiential Learning Theory and Christine Tanner’s Clinical Judgment Model as the theoretical framework, emphasizing the development of thought processes that enhance learning. A quasi-experimental quantitative research design was employed to assess whether virtual simulation with instructor feedback improved clinical judgment among undergraduate nursing students. A pre- and post-case study assessment using Next Generation NCLEX (NGN) questions, based on the Modified Lasater Clinical Judgment Rubric, was developed to measure clinical judgment before and after virtual simulation. The case study results were graded, and clinical judgment development was evaluated using the Modified Lasater Clinical Judgment Rubric by Christina Zamaripa. Results: The results indicated that the clinical judgment scores on the pre-case study assessment were higher than the post-case study assessment scores, following the virtual simulation with instructor feedback. Despite the decrease in scores, on average, the level of clinical judgment remained the same at the developing. Regarding individual components, skillful response within the responding phase showed significant improvement from the pre- to post-case study assessment score following the virtual simulation, however, the moderate negative effect size indicates that the change was not very large. Conclusion: Findings from this study indicate that while students reported positive perceptions and felt the virtual simulation enhanced their learning, clinical judgment scores declined post-intervention. Despite student engagement, the simulation did not lead to measurable improvements, likely due to factors such as class length, content complexity, and gaps in foundational knowledge. When examining individual components and scoring, students showed some variation in their clinical judgment development. For certain components, their scores declined, while in others, their clinical judgment levels remained unchanged on average. For responding, both the scores and clinical judgment level declined for confident tone. As for well-planned intervention and flexibility, although their scores declined, students remained at the developing level of clinical judgment. When it came to clear communication, the score improved, but their clinical judgment level remained at developing. As for skillful response, the score improved significantly, yet the clinical judgment level stayed at developing. In the reflecting phase, both evaluation/self-analysis and commitment to improvement scores declined, but the clinical judgment level remained at developing. During the noticing phase, scores for focused observation declined, but the level remained unchanged at developing. For recognizing deviations from expected patterns and information seeking, there was a significant decline in both the scores and clinical judgment level. Lastly, in the interpreting phase, there was a notable decline in both scores and clinical judgment level for prioritizing data and making sense of data. These results suggest that the success of virtual simulation in developing clinical judgment is influenced by the students' existing knowledge base. Several factors highlighted in student feedback may have contributed to the decline in post-assessment scores. Despite its limitations, this study offers an innovative teaching approach and a valuable tool for assessing students' knowledge and clinical judgment skills.