Today we’re not only facing a critical shortage of skilled nurses, exacerbated by pandemic burnout layered onto the aging nursing workforce, but we’re also confronted with the fact that most licensed nurses are simply not patient-ready on their first day of practice.
While approximately 23% of novice nurses achieved an acceptable competency score for entry-level clinical judgment in 2015, that has decreased to an alarming 9%, according to a study in the Online Journal of Issues in Nursing.
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What’s more, this is at a time when nurses are having to shoulder more patients as the boomer generation seeks care, with more critically complex issues, according to this year’s annual survey by a nurse staffing company.
We urgently need to produce more qualified nurses, at a faster pace. Nurses provide pivotal feedback to help direct the patient’s plan of care and make best use of the provider’s time with the patient. So how do nurse learners get to practice making potential life-altering decisions in a high-acuity environment, when, as with the Apollo 13 rescue mission, “failure is not an option”?
Luckily, we have the opportunity and tools already available to make a difference.
Changing roles
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A nurse’s role has morphed over recent years, and today one priority is to act as the eyes and ears of the whole healthcare team. Providers may only be able to spend a brief window of time with a patient. Meanwhile, the bedside nurse is present throughout the day and can observe trends in the patient’s condition, communicate assessment findings, and recommend interventions to help the patient.
The National Council of State Boards of Nursing (NCSBN) defines clinical judgment as an iterative decision-making process where nurses observe and assess clinical situations, prioritize client needs, and generate evidence-based solutions to provide safe client care. Eye-opening research a few years ago found that nurses were involved in 50% of patient errors, and 65% of those errors stemmed from a lack of clinical judgment. These surprising statistics are among the reasons behind the changes to the 2023 NCLEX nurse licensing examination to put more emphasis on clinical judgment.
Experiencing nursing through clinical rotations is one way for students to develop clinical judgment, but it is primarily observational and placements can be scarce. During the height of the pandemic, some rotations were curtailed for both patient and learner safety.
The NCSBN Clinical Judgment Measurement Model (NCJMM) includes these six cognitive steps:
- recognize cues
- analyze cues
- prioritize hypotheses
- generate solutions
- take action
- evaluate outcomes
As a nurse educator, I have taught clinical. When taking students into a clinical setting, I noticed that much of the time, their patients were stable over their entire 12-hour shift. If the patient did become unstable, the supervising nurse would step in and the student would observe, not getting the chance to exercise and develop their own clinical judgment. While it was a valuable experience for them to draw upon, they didn’t practice making those decisions on their own. There was no safe opportunity for trial-and-error.
Learning opportunities
Obviously, we don’t want patients to get hurt; we want the experts to provide the care. The challenge is that nurse learners doing clinical rotations must also have safe and effective opportunities to develop and flex their judgment muscles in high-acuity situations that can be difficult to predict or hard to simulate.
In my own training, for example, I spent a clinical rotation on a neurology floor. When I was challenged with caring for a patient having a heart attack, I did not feel adequately equipped to provide the best assessment as I hadn’t had that real-life experience up to that point.
This is where the value of virtual reality (VR) simulation comes in. It provides a safe environment and myriad practice scenarios without risk of patient harm, where nursing students can be provided with curated structured opportunities to put into practice the six steps that develop solid clinical judgment.
Immersive VR, a multisensory experience where learners don headsets, offers the opportunity to see diverse patients in unique situations, to practice therapeutic communication, and to be able to self-reflect upon how they would care for patients in the future. By experiencing a full library of patients that they’re able to care for successfully — that’s where developing clinical judgment comes in. They can pull from all of those virtual experiences to infuse the judgments they make in real life.
Virtual reality simulations not only allow, they encourage students to make mistakes. I like to say that students get into the trenches and experience those invaluable “a-ha!” moments when they figure out how to get out of the trench — on their own. Afterwards, they can discuss with their instructor the errors they made, what to do differently the next time, and how to move forward.
With nursing faculty also in short supply and a wave rapidly approaching retirement age, virtual reality simulations can help bridge the gap between learners needing supervised clinical experiences, and time-pressed preceptors, who have their own patients to care for in addition to guiding novices in clinical settings. A good VR solution provides feedback on critical actions and performance gaps, encourages reflection, and can also provide questions on unfolding cases.
Coexisting with manikins
Of course there are challenges to overcome when adopting immersive VR, and it may not be right for every scenario. You have to consider the learning objectives. If you want to teach learners how to do CPR, for example, a manikin has an advantage in simulation because VR doesn’t — yet — offer the capability to feel touch (depth and recoil) when doing compressions.
But if you want to work on assessing a patient in distress and practicing therapeutic communication, VR allows the patients to make eye contact and respond with dynamic facial expressions. The patients change overall throughout the simulation, just as they would in real life, rather than remaining static or requiring reprogramming or additional moulage (as might a manikin). Immersive VR, where learners don headsets, makes it easier for the learner to experience a high degree of presence and suspend disbelief, helping the simulated yet multisensory experience seem authentic.
Different modalities of simulation such as manikin and VR simulation can coexist, not compete, to provide students with the best learning experiences to equip them to make hard, quick decisions and to do so in an empathetic way with patients. Educators can choose which modality best suits the learning objectives they want their students to accomplish, as well as the space and resources they have available.
VR supports nurse educators in preparing learners to practice communication, prioritization, and clinical judgment development skills, which is why some nursing colleges, such as Illinois’ Mennonite College of Nursing, are breaking ground on full VR-equipped simulation centers.
By providing a variety of evidence-based, realistic patient scenarios and interactive, even enjoyable simulations, a virtual reality solution allows nurse learners to build their cognitive, affective, and psychomotor skills while practicing the steps in the clinical judgment process. When nurses are well prepared for tackling their licensing board examination, they become more confident and competent in their decision making once they graduate, which ultimately leads to better patient care outcomes.
Photo: PonyWang, Getty Images
Christine Vogel, MSN, RN, CHSE, CHSOS, is a lead nurse educator at UbiSim , where her passion for innovation in nursing education drives her to design, pilot, and evaluate evidence-based immersive virtual reality (VR) simulations for nurse learners. With a distinguished career that extends over 25 years in nursing, including more than a decade dedicated to academic roles, her work is inspired by a commitment to enhance the educational journey of nurse learners and improve patient care.
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