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HealthJanuary 14, 2021

Building clinical judgment during a pandemic: Exploring flexible foundational learning experiences that address the Next Generation NCLEX

By: Kristen M. Poston, DNP, NP-C
Will nursing education ever go back to “normal” post-pandemic?

Educational restructuring created by the Covid-19 pandemic is rapidly intersecting with the evolution of the Next Generation NCLEX (NGN). This juxtaposition has required faculty to reconsider and reorganize the delivery of activities that build clinical decision-making in pre-licensure nursing students. It’s time to consider how we plan to address these vigorous changes to meet our needs in the here and now and to prepare for an undoubtedly dynamic future in nursing education. With an ever-changing learning environment, how can faculty develop high-quality clinical judgment simulations and activities, that meet NGN outcomes and objectives, and transition these online at the drop of a hat when needed?

Now more than ever, incoming nursing students need quality learning experiences that facilitate the transition from novice nursing students into reliable clinical decision maker from the outset of their training. These students also need support in managing their cognitive load, navigating multiple electronic platforms, and attaining high-quality learning outcomes and objectives in the event in-person simulation and skills experiences are moved online. Faculty have the unique challenge of fostering students that are well-versed in NGN innovative item types while reacting and adapting to dynamic changes and restrictions created by the pandemic. Additionally, faculty have an ethical obligation to ensure quality experiences for students whether they complete an activity in-person or virtually. If a student, or students, must miss a critical in-person simulation experience, is assigning them an alternative exercise on the same content sufficient? Or can that student participation in the simulation “virtually” if the simulation is recreated? Constructing clinical judgment activities that facilitate achievement of NGN competency across courses within a program, and that can easily transition from in-person delivery to an online format, is paramount in not only surviving but thriving in this “new-norm”. Leaning on the NCSBN Clinical Judgment Measurement Model (NCJMM) as a foundation for creation and implementation is one way to accomplish this.

The NCJMM aims to facilitate nursing education methods that appropriately foster and measure students’ abilities to make appropriate clinical judgments to prepare them for the increasing challenges newly licensed nurses face. Layers three and four can be implemented in the form of an actionable model and used as a tool to develop clinical decision making. Specifically, Layer four can provide a pathway for pushing past the basic introduction of the NGN Case Study by introducing a variety of conditioning factors, both individual and environmental, that create realistic client scenarios.

Developing clinical judgment simulations and activities

So what are the main points faculty must address to ensure that they develop clinical judgment simulations and activities in a high-quality fashion? How do faculty ensure reproducibility but allow for malleability in the event they must be moved online? How can faculty reduce cognitive load among students transitioning within this semi-hybrid environment to meet learning objectives and achieve quality outcomes? How can programs address this across courses and across the program as a whole? The following three points discuss solutions to these challenges:

1. Introduce the NCSBN Clinical Judgment Measurement Model (NCJMM) early in the program.

Begin to expose students to the model and NGN item types early on at the foundational level. Incorporate NGN Case Study item types from the outset of the program and align these critical skills and simulation experiences into NCJMM action model experiences. This allows for smooth transition of foundational principles across first semester courses, and into higher-level decision-making courses like med-surg etc.

2. Explore the key learning activities and simulation experiences in the courses you teach, and in your program as a whole. Consider creating both in-person and virtual versions of these experiences that adhere to high-quality standards. Assign these virtually when needed. Incorporate NGN concepts into these experiences from day 1.

Once key experiences are identified, it is important to consider the following: Can these critical experiences be created virtually as well to ensure an easy transition to an online format in the event you must move your simulation online for sick or quarantined students, or due to campus closures? If your program is like many others across the country, situations are arising on what seems like a weekly basis requiring some or all students to be provided alternative experiences. Consider the following items to create malleable simulations and activities that ensure an equitable experience for all of your students regardless of participation format:

  • Adhere to established principles from the International Nursing Association for Clinical Simulation and Learning, as well as guidelines from your respective state board of nursing. Ensure that experiences are designed with measurable objectives to achieve expected outcomes, and thread these throughout your course and program.
    • Whether a student gets the in-person version, or the virtual version, confirm that they are not getting “a lesser alternative experience,” but rather the experience that was intended for them during your initial design of the activity and your course.
  • Utilize available technology to bring your critical activities up to speed in the virtual environment. Create opportunities not only to increase knowledge through learning by examining NGN case studies but affect behavior by impacting student decision-making through matching these case study item types to the live environment. Move the patient along a healthy recovering pathway vs a declining patient pathway based on the student’s recognition of appropriate cues and correct item type decision making. Video record the in-person version of critical simulation experiences ahead of time, and transition these into functional virtual simulations. One example of this is as follows:
    • At the foundational level, video record an in-person simulation that addresses a key concept like “principles of oxygenation”. Develop QR codes with NGN case study item types (easily created and shared in a program like Microsoft Forms). Based on the student’s decision making, create 2 different pathways dictating patient outcomes (recovering vs declining).
    • For students participating in-person, introduce QR codes with NGN item types that students can scan at critical junctures/stations in their decision making. Allow them to see how their decision making at that stage, matches with NGN-style items. Rather than having them just recognize and analyze cues that are introduced within a passive NGN case study item, ask them to log into their simulated EHR and find those cues instead, then answer the question. This more accurately replicates the real-world environment in which they will be required to quickly log-in and navigate a live EHR and identify relevant information when managing actual patients. Based on their correct or incorrect recognition of cues and decision making, move them along on the recovering vs declining pathway.
    • If you must provide the experience virtually, incorporate relevant snippets of the video-recorded simulation. Include video conversations with the patient, hand-off reporting, vital signs on the monitor, and the patient’s breath sounds etc. Pause them similarly at critical junctures/stations and share the QR codes on the screen at these junctures. Ask them to log into their simulated EHR just as you would have in the live environment to pull critical cues, data etc. Then apply that to the NGN item. The student will be moved along the scenario pathway based on their responses (recovering patient vs further decline) and will progress through additional snippets of the recorded video scenario based on their selections.
    • Student instructions and progression through a virtual experience are easily accomplished in a variety of software as noted above, and can look similar to this:

Welcome to the Oxygen Games! Each student should progress through parts 1, 2, 3, 4 of the simulation. At each applicable juncture—after part 1, 2, 3, 4—QR codes will be available to scan. Upon scanning the QR code, enter your simulated EHR to retrieve additional information about the client. This information will require you to recognize and analyze EHR cues, interpret assessment findings, and select appropriate interventions to answer the NGN item types. Based on your responses, you will be prompted further down a client pathway (recovering patient vs declining patient) and applicable video snippets and NGN item types will be scanned via QR codes accordingly. Good luck!

3. Create continuity between and across courses.

Minimize cognitive load and increase familiarity with electronic programs to maximize exploration of clinical judgment. With the addition of a multitude of virtual simulation opportunities, comes the addition of navigating a multitude of websites, log-ins, and platforms. Consider creating your dual in-person and virtual activities across all courses in a similar format. This can help mitigate student cognitive overload by requiring “yet another” virtual platform, maximizes faculty and student time, and allows for pre-briefing of experiences to focus on key learning objectives and principles rather than website/vendor navigation challenges.

Allow students to expand upon their foundational knowledge by utilizing cases with a familiar patient, family, or nursing unit within your simulated electronic health record (EHR), then expand upon those cases to incorporate fundamental aspects from each course in your program. Educators can lean on the principles of the NCJMM during this process, as one of the benefits of the actionable model is that it’s measurable and easily reproduced. Prioritize Layer 4 of the NCJMM during this process by altering conditioning factors that set the stage for each simulation or learning activity. For example, introduce a patient and family member in the nursing home setting during your foundational courses during your oxygenation scenario. Focus on recognizing assessment cues in your health assessment course, and nursing interventions in your foundations course. Reintroduce this patient with the simulated EHR in med-surg in the acute setting requiring intubation, and again in population health in a community setting requiring at-home care for chronic lung disease. With each of these re-introductions, alter the conditioning factors that the nursing student must manage. Make them dig back into the simulated EHR to review historical medical record cues from the initial nursing home stay that may be relevant now during their acute admission. Introduce family dynamics, cover therapeutic communication, and highlight policy topics as you evolve patient-family members, care settings, and consideration of institutional policies etc.

In conclusion, consider how you can best support each and every student whether they are able to participate in-person or not. Set the stage for building stellar clinical scenarios, activities, and simulations by introducing and prioritizing NGN principles early on in your program. Consider using the NCJMM model to create your own NGN case studies and test items that fit your outcomes and objectives. Begin to incorporate these into your simulation activities and clinical judgment application experiences early on. Transition these principles and experiences across your program and continue to create opportunities to convert these online when needed through consistent and familiar platforms to ease student cognitive load and faculty workload.

Kristen M. Poston, DNP, NP-C
Expert Insights Contributor for Wolters Kluwer, Nursing Education
  1. INACSL Standards Committee (2016, December). INACSL Standards of Best Practice: Simulation©: Simulation. Clinical Simulation in Nursing, Volume 12, S5-S50.
  2. National Council of State Boards of Nursing. (2020). Next generation NCLEX project.
  3. National Council of State Boards of Nursing. (2020). Layer 4 of the NCSBN Clinical Judgment Measurement Model (NCJMM). Next Generation NCLEX News.
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