Development and psychometric testing of a Clinical Reasoning Evaluation Simulation Tool (CREST) for assessing nursing students' abilities to recognize and respond to clinical deterioration
Introduction
Failure to recognize and respond to patient deterioration is a global problem in acute healthcare settings (Watkinson and Tarassenko, 2012), with research reporting that this results in 23% of patient safety-related hospital deaths (Donaldson et al., 2014). In contemporary healthcare, there are increasing numbers of older and acutely ill patients with complex health problems who are at risk of adverse events, being cared for in general wards (Kyriacos et al., 2011). Adverse events are defined as unintended complications and injuries that lead to cardiopulmonary arrests, unplanned intensive care unit admissions, and mortality (Taenzer et al., 2011). These adverse events are often preceded by signs of deterioration (Franklin and Mathew, 1994) and thus, timely detection and appropriate interventions are important in ensuring safe patient care (Hillman et al., 2002). Although Rapid Response Systems (RRS) have been widely implemented to manage critical patient deterioration (Gao et al., 2007), a failure to recognize clinical deterioration in the early stages frequently results in suboptimal activations of the response teams (Sandroni and Cavallaro, 2011).
Poor clinical reasoning skills have been identified as one of the key reasons that nurses fail to recognize and respond appropriately to deteriorating patients. Banning (2008) defines clinical reasoning as the process of utilising one's knowledge and expertise to seek a solution in a clinical situation. Hoffman (2007) conceptualises clinical reasoning as a process where one gather cues, interprets them, understands the clinical problem, plans and performs interventions, evaluates the effectiveness of the interventions, and learns from the whole process through reflection. The ability to collect and cluster cues is essential for a nurse to identify patient problems (Hoffman et al., 2009). Although previous exposure to similar experiences results in ‘pattern recognition’ or intuition and play a key role in helping nurses to recognize and respond to clinical deterioration (Cioffi, 2000), overreliance on intuition can increase the likelihood of errors (Odell et al., 2009). The ability to apply clinical reasoning in providing evidence-based rationale to explain physiological changes and guide nursing actions is crucial in helping nurses to recognize and respond appropriately (Preston and Flynn, 2010).
A study by Cooper et al. (2010) reported a significant deficit in nursing students' clinical reasoning skills and ability to recognize and manage patient deterioration. Although clinical placements provide valuable learning experiences, opportunities for exposure to patient deterioration situations cannot be guaranteed. Additionally, when these types of critical situations occur, students are often relegated the role of passive observer without hands-on experience (Levett-Jones et al., 2010). To address these issues, educators have increasingly using simulation (Buykx et al., 2011). Simulation offers a hands-on experiential learning approach where manikins and other modalities can be used to facilitate students' learning in the assessment and management of patient deteriorations (Liaw et al., 2011a).
Although a number of studies attest to the effectiveness of simulation in enhancing nursing students' confidence, knowledge and clinical skills, the evaluation of clinical reasoning skills is often inconsistent or neglected (Fisher and King, 2013). Further, most reported studies use self-report measures or knowledge acquisition as outcomes. The use of multiple choice knowledge tests may not be sufficient for detecting any change in clinical reasoning abilities (Carter et al., 2015). Although there are available tools to measure clinical reasoning skills in nursing simulation (Lasater, 2007, Doolen, 2012), the measurement of such skills does not address the complexity of nursing practice in clinical deterioration. A systematic review on evaluation tools to measure critical thinking development highlighted the need to develop a discipline specific instrument that evaluates the application of critical thinking to practice (Carter et al., 2015). This study aims to develop a valid and reliable tool known as the Clinical Reasoning Evaluation Simulation Tool (CREST) for examining nursing students' ability to recognize and respond to clinical deterioration in a simulated learning environment.
Section snippets
Methods
A three-phase prospective study was conducted from August to December 2015. Phase 1 included the development and content validation of the CREST; Phase 2 involved psychometric evaluation of the parallel scales; Phase 3 involved usability testing.
Construct Validity
The known-groups technique was used to evaluate the construct validity of the CREST by comparing the scores between Yr-2 and Yr-3 participants. Table 1 shows no significant difference between the two groups in all demographic variables except the length of clinical experience (p < 0.001). The Yr-3 students had a significantly higher number of weeks of clinical experience than the Yr-2 students (p < 0.001). As shown in Table 2, the Yr-3 students had significantly higher median total scores than the
Discussion
The CREST developed in this study was based on a model of clinical reasoning from the work of Levett-Jones et al. (2010). The model was developed from an extensive literature review and research that examined the thinking strategies of novice and expert nurses in the clinical practice (Hoffman et al., 2009). The relevance of the model in developing the clinical reasoning skills to recognize and respond to clinical deterioration was supported by previous studies (Lapkin et al., 2010, Hoffman et
Conclusions
The importance of developing effective clinical reasoning skills for recognising and responding to clinical deterioration has been emphasized in pre-registration nursing training. Although simulation has become a commonly used strategy to acquire these skills, an evaluation instrument is needed to measure nursing students' clinical reasoning skills and to demonstrate the effectiveness of learning strategies. This study developed and established a valid and reliable tool to measure clinical
Acknowledgement
We would like to thank the nursing students and nursing faculty staff from National University of Singapore for participating in the research study. We also thank the NUHS Medical Publications Support Unit (PSU) for providing editing services for this manuscript.
Conflict of Interest
No conflict of interest has been declared by the authors.
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