First Advisor

Records, Kathryn A.

First Committee Member

Dunemn, Kathleen

Second Committee Member

Henry, Melissa L. M.

Third Committee Member

Allen, Michael

Document Type


Date Created



Nursing clinical judgment is evident when multiple complex decisions are made quickly resulting in positive patient health outcomes (Lasater, 2007; Tanner, 2006). Patient safety is dependent on effective nursing clinical judgment but this skill has been declining among new graduate nurses, resulting in only 9% demonstrating entry-level competency in 2020 (Kavanagh & Sharpnack, 2021). To mitigate this decline, nurse educators need to develop methods to teach this skill with increased effectiveness. Tanner’s (2006) clinical judgment model described four cognitions of clinical judgment. Lasater’s (2007) clinical judgment rubric (LCJR) was developed to build on this model and provide leveled language in 11 dimensions of clinical judgment. The rubric was designed to be used by clinical instructors to evaluate and provide feedback to their prelicensure nursing students about their clinical judgment during simulation (Lasater, 2007). The nursing literature provided many examples of the use of the LCJR in various ways to evaluate and teach clinical judgment (e.g., Bussard, 2018; Fawaz & Hamdan-Mansour, 2016; Hines & Wood, 2016). Among specific pedagogies, the literature about how to teach and measure clinical judgment related to in-person clinical was limited. To address this gap, this study tested direct instruction about applying the LCJR’s clinical judgment behaviors to in-person clinical experiences. According to Barbash (2021), direct instruction was developed by Englemann and colleagues who emphasized well-designed curricula in which students were led in a stepwise fashion using clear, applicable examples and explanations to the goal of mastery (Stockard et al., 2018). The direct instruction designed for this study explained and illustrated the clinical judgment language in the LCJR. An example with a fictional nursing student was included with the direct instruction to complement the LCJR and facilitate students’ demonstration of behaviors indicative of clinical judgment. The following research question guided this study: Q1 Among prelicensure nursing students, how did direct instruction about how the Lasater’s clinical judgment rubric (LCJR) could be applied to their in-person clinical experiences compared with no direct instruction affect their clinical judgment ratings from the end of first semester to the end of second semester? A convenience sample of 68 prelicensure nursing students participated in a two-group, quasi-experimental study. The control group data were collected first from students who received the traditional program of study. The intervention group was recruited later to minimize a potential cross-over effect; this group received direct instruction during semester one and/or semester two. Ratings from observations of each participant during simulation at the end of semester one and semester two were analyzed using SPSS. The Wilcoxon paired signed rank test was used to compare the ratings within the control and intervention groups and the Mann-Whitney U test was used to compare the ratings between the control and intervention groups. The final control group (n = 17) showed the expected increase in clinical judgment ratings from semester one to semester two (Manetti, 2018). In contrast, the intervention group (n = 10) did not show an increase in clinical judgment ratings from semester one to semester two. As a result, the hypothesis that there would be a greater increase in clinical judgment ratings for the intervention group than the control group was not supported. This research contributed a clinical judgment direct instruction program that was aligned with assessment using the LCJR to the nursing literature. Further, processes for establishing interrater reliability with the LCJR supported the use of this as a valid assessment strategy. Direct instruction was easily integrated into clinical teaching practices. Lower than projected participant recruitment and high attrition limited the validity of the findings of this study. Further studies are needed on direct instruction and other teaching strategies that might help prelicensure nursing students develop their clinical judgment skills so their transition to practice after graduation could be facilitated and the quality of patient care could be maximized.

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