Abstract
Clinical experiences are essential for the development of clinical judgement in nursing students. Clinical experiences offer students situated and contextual learning opportunities to apply their theoretical knowledge to patient care and make effective clinical judgements. However, students’ learning opportunities vary widely in the clinical environment and this may influence their ability to acquire necessary clinical judgement skills. Further, access to clinical learning opportunities for many nursing schools is increasingly problematic due to limited clinical placements. In response, nursing schools are exploring simulations as alternative learning opportunities to support the development of clinical judgement in nursing students.
Research shows simulations are a valuable educational tool to prepare students for the clinical environment. They are especially useful as a practice environment that has no patient risk. There is also increasing evidence that simulations are helpful for developing clinical judgement. In nursing education, this evidence is based mainly on the evaluation of students’ clinical judgement skills using the Lasater clinical judgement rubric (LCJR). However, other studies report nursing students are often anxious in simulations, they may find cue recognition difficult and they may struggle with the contrived nature of the simulation. The LCJR does not directly account for these contextual factors, therefore, a student’s clinical judgement score in simulation may not accurately reflect their clinical judgement ability. As such, understanding the students’ voice and their experiences in simulations is critical to designing an environment that enriches student learning, and ultimately the development of clinical judgement skills.
This exploratory case study investigated the experiences of third-year undergraduate nursing students in simulations and collected stories about their experiences in the clinical environment. This study places an emphasis on the student’s voice. It aims to add to the ongoing dialogue about the potential use of simulation as an alternate learning environment to foster the development of clinical judgement in nursing students. To fulfil these aims, this thesis considered two research questions:
1) How do nursing students experience simulation as an environment for learning?
2) How do nursing students’ learning experiences in simulation and clinical practice influence their development of clinical judgement skills?
The study employed a qualitative interpretative inquiry, involving: observations of simulations; one-to-one interviews; a collection of student stories from clinical practice; and the review of documents pertinent to the simulations. Twelve third-year nursing students participated in the study. The observation notes, interview data and clinical stories were analysed using a general inductive approach to categorise and derive key themes.
The study identified several themes that deepen our understanding of students’ experiences in simulation and in the clinical environment to develop clinical judgement. First, students’ perceptions of realism, comfort with role-play, preparation for the simulation, and collegiality and trust within their simulation group influenced their experiences in simulation. Accordingly, some students may find it more difficult than others to leverage the learning opportunities simulation offers. Second, there may be an unintentional effect of being observed in simulations, in particular, performance anxiety and a fear of making a mistake. In addition, separating the novice learner from the lecturer with the expert knowledge could overwhelm the student and make problem-solving difficult.
Third, students’ learning experiences in simulation and clinical practice were very different; therefore, the environments provided different learning opportunities. In the clinical environment, students’ felt a strong sense of responsibility for the patient outcome because they were working with real patients in real situations and they connected their learning to the emotions this induced. In comparison, simulations could feel less authentic, and, for some students, this made it challenging to connect with the learning. In the clinical environment, students had to respond in complex and unpredictable situations, whereas in simulations, the purposeful intent and end point of meeting learning outcomes meant the student’s response had the potential to be predictable and formulaic.
In summary, a number of interlinking factors influenced students learning experiences in simulation. These included participant-related factors, facilitation of the simulation and the learning context. The experiences of these students are useful to consider when planning simulation and clinical experiences to develop clinical judgement in nursing students.