Building Clinical Judgment: Scaffolding Simulation for Nursing Education

In this episode of NLN Nursing EDge Unscripted, host Raquel Bertiz from the National League for Nursing’s Center for Innovation in Education Excellence is joined by Dr. Beth Rogers, an assistant professor at Texas Christian University and associate editor of Clinical Simulation in Nursing. Together, they explore the critical role of simulation design in fostering clinical judgment, emphasizing the importance of foundational skills and intentional scaffolding to reduce cognitive load. Dr. Rogers shares insights from her research, highlighting how gradual progression in complexity enhances learner confidence and competency. This engaging conversation underscores the need for strategic simulation practices to better prepare nursing students for real-world challenges.

Dedicated to excellence in nursing, the National League for Nursing is the leading organization for nurse faculty and leaders in nursing education. Find past episodes of the NLN Nursing EDge podcast online. Get instant updates by following the NLN on LinkedIn, Facebook, Twitter, Instagram, and YouTube. For more information, visit NLN.org.

Transcript

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[Music] Welcome to today's episode of the NLN Nursing EDge Unscripted. I am Raquel Bertiz, your host from the  National League for Nursing Center for Innovation in Education Excellence. In today's episode,  we're diving into an essential topic in nursing education simulation design and its role in  fostering clinical judgment. With us today is Dr. Beth Rogers, an expert nurse educator who  is deeply immersed in simulation education practice and research. Dr. Rogers is currently a professor  at the Texas Christian University and also the associate editor of Clinical Simulation  in Nursing. Dr. Rogers, welcome! Thanks so much Raquel. Thank you for having me and thanks to the  listeners for joining in today. Okay, I'm ready to dive into this conversation. It's amazing  that today we have so many options in implementing simulations, but how do we ensure that we're doing  them effectively? So let's start with your research findings. What did you uncover about simulation  and clinical judgment? Well, yeah, thanks for the opportunity to let me share my research. You know,  some of my research has revealed that the complexity of simulation scenarios has a  direct impact on clinical judgment outcomes and I think it's really kind of important  that we let that sink in because learners really struggle with clinical judgment when complexity  is increased in the slightest, especially if they haven't had time in simpler routine situations to  develop like foundational skills. So one of the key findings from my research is that learners would  have really likely benefited from spending more time in those routine, less complex simulations.  A more gradual progression would allow them time to master basics and build clinical judgment in a  more manageable way. As I reflect more and more about the research that I did, I think  another key takeaway from my research relates to competency and that it develops at an  individual pace. We really have to keep that in mind because if we push learners into high stakes  and complex sims too soon we can actually hinder their clinical judgment development and this is  something that I think we observe in simulation like on a day-to-day basis. I just  had this conversation recently about how we can spend an entire semester helping students  build confidence in med administration and they can make progress but maybe in the beginning they  still like run out of time to give meds or give some slightly incorrectly and they don't really  master those medication skills and then we put them in an urgent and high pressure  stimulation and they skills just completely fall apart. So if we don't let students accurately  and consistently apply what they've learned to those routine situations, how can we expect them to  handle really highly complex situations?  I do think I should tell you that the research  that I have done is in junior students, which is like their second semester of nursing school.  And we need to know more about the other levels too, but there's lots of literature showing that  what I found is what other people find too - that complexity matters and whenever we put  students in really complex situations they can't always manage them. We need to know what  we can reasonably expect students to do to better handle those difficult situations. Those are great  points and they really highlight how foundational skills need time to develop before we throw  our learners into more complex scenarios. And that really brings us to a bigger conversation  in nursing education - how we think about time in in simulation? We often put a premium or we measure  success of our simulation programs by the amount of time spent in simulations or clinical rotations.  I know that's very similar to my experiences as well that we would like to have this many  hours in simulations and this many hours in our traditional clinical rotations, but your research  suggests that there's really more to it than just hours logged in. So how do you think about  this connection to the broader conversation about time spent in learning experiences in simulation?  Yeah I think that's a great question. I think my research confirms that time alone doesn't  guarantee learning progression. You know, at the NLN conference there was a a big call to shift  away from thinking about education as time served, you know essentially like, yeah, exactly and instead  of focusing on ensuring, we need to ensure that there's mastery of essential skills, right, so  you know this really resonated with me because I think a lot of simulation programs approach them  as a series of essential experiences and that if you go through the, go through these experiences  you're going to gain what we want you to gain.  But the idea really is that, well, I guess the idea  that we use is that the more scenarios students are exposed to the better prepared they'll be for  practice. But I don't know that that's necessarily true to me. I was talking to a colleague the other  day and he shared a great analogy. He was like, you know, it's like we're trying to teach students  how to cook by handing them a bunch of different recipes without first teaching them the  foundational skills of cooking. Chefs, to graduate from chef school, don't have to master every single  recipe. They master knife techniques and seasoning and balancing flavors and then they apply that to  their own recipe and make it their own, their own like touch, right. But in nursing education,  I think we should kind of do the same thing. We should prioritize building a strong  foundation and routine, less complex scenarios. So we should like focus on basic assessment,  communication, decision making skills before  putting them into complex high pressure  scenarios because if we push learners into complex situations too soon, it's like asking  somebody to prepare this extremely intricate dish before they even know how to boil water.  Well, that's such a great analogy kind of like I kind of get that right so learning the basics  first so it it really illustrates how crucial it is to give learners the time and space like,  well, like a kitchen in all its amenities right and in our similar circumstances it's the simulation  lab, the clinical labs to master foundational skills first before diving into more complex  scenarios. And really this ties into a larger issue when we often see nursing education how  we think about time in simulation. So it's not just really the number of hours, right?  It's about how effectively that time is used to build up skills, step by step, and this is  where cognitive load becomes really important.  You've researched how simulation design impact  learners' learning ability to manage the demand placed on them. So how do you think a cognitive  load factors into these decisions and how does it influence how we as educators should be  designing simulations? Oh yeah, I think cognitive load is really crucial to clinical judgment  development. We know from cognitive load that the way we design sims can either help or overwhelm  learners. You know, I've found that factors like sim fidelity, time pressure, multitasking, and we've been  talking about task complexity, those all increase cognitive load. And when learners are placed in  like a really complex scenario too soon they end up overloaded. They have more stress, uncertainty  they have multiple competing priorities to think about ,and it makes it difficult for them to think  and make good decisions and learn. But on the flip side, when we start like with simpler situations  that focus on the basics, learners can put their energy, their mental energy, into mastering those  core skills. And so it helps them build confidence and confidence, making it easier to like handle  more complex situations down the line. As we, or as students gain mastery, they can tap into like  long-term memory and not have to remember as much because they can use what they've already learned  to tackle the new challenges. And you know in sim, we're finding things like pre-briefing, repeated  practice, modeling, really help reduce cognitive load. But these strategies are ,they all are  kind of related to the scaffolding conversation because they all intend to give learners support  to reduce their cognitive load as they move forward. It's really about finding the sweet  spot between giving learners the right amount of challenge so they're not overwhelmed but pushing  them and growing to improve and that's, that's I think our role as nursing educators and nursing  simulationists. Yeah. Yeah, I agree with that that's such an important point. And those strategies can  actually apply not just in simulations but to all other learning activities as well. But let's  get back to what strategies can educators use to scaffold complexity and promote growth in  learners? That's a good question. I think we all want to know that answer.   I think that scaffolding complexity really starts with meeting learners where they are and building  from there. Right now, we assume that we know where students stand because of previous  coursework. So, for example, we assume that because students have taken pharmacology that  they know their medications. But how many times have you thought or heard someone say, man, I know  they were I knew students were taught this and that class. Why can't they remember that in this  sim? But that's kind of where we run into trouble. Just because students were taught something or  took a class in a previous course or introduced something in a previous course doesn't mean that  they've mastered it, right. So students might know the information but not know how to apply it or  think through a situation. So our first step is really understanding the foundation that  students bring to us, what skills do they already have, how comfortable are they with like basic  skills, and when we know where they stand, then we can design sims that meet them where they are and  like gradually increase their skills instead of assuming where they're at and jumping ahead too  quickly. So after we know where they are, I think the next step is ensuring students have  enough time to master simpler, routine, more like skills before we move them on into more complex  situations, because that'll give them a stronger foundation and confidence to tackle  that same situation later on in a more complex situation. I mean it's kind of like  building a house - you don't build the second floor until you have a solid foundation otherwise it's  going to crumble. And we can look to other professions for for guidance here on  this scaffolding topic. Like take engineering for example. Engineers don't start by having students  design a skyscraper. That is not their expectation of students whenever they graduate.  They first focus on the fundamentals of understanding physics and the materials they're  working with and how structures fit together and the kind of key concepts of what is needed to make  a building work. It's not about rushing to the final product of designing the most  complicated task. It's about grasping the why and understanding the thinking and how behind a design  so that whenever they get to a complex project they can use what they know and apply it to that  complex situation. And that's really what we should do in nursing. We need students to master core  skills before they face those more intricate sims. So to me, I think a great  way to scaffold effectively is to first break down like sims into smaller manageable pieces and focus  on the skills like one at a time. For example, maybe early on you can focus on basic clinical  judgment skills like assessment or prioritization and like a low stakes routine scenario. But then  once they master that you can add in complexity with maybe time pressure or taking care of two  patients instead of one. But it doesn't take a lot of complexity to overwhelm students and I  know you were at the conference at the NLN Summit in the fall and you got to hear Dr. Jared Kutzin  give us a really good example of scaffolding and I really think that was a really great example. In  case you weren't there, he told us that in his sim program he starts with a knowledge  assessment to check can see where students are. Do they understand the material? And then they  have to actually pass it to move on, unlike nursing school. A 'C' on an exam gets you to  move forward, but they have to pass that knowledge test. So after that he'll introduce  a skill related to the knowledge and then maybe build complexity with applying it to the  real world situation or a virtual sim, but he scaffolds within a skill, within a concept. And the  key concept is it's a step-by-step approach that really helps learners build skills at a manageable  pace and master a part of the skill, add more complexity. And you know, there's a lot of ways  to achieve that example of scaffolding, but at the end of the day, scaffolding is about understanding  the building blocks of learning and really giving learners the experience at the right time so that  they can grow and be ready for more challenging situations. And that illustrates starting with  a solid foundation right and then building from there rather than jumping straight into  to complex situations in simulations, which, by the way, we love to do as nurse educators sometimes.  Also I think highlights the need for intentional planning and designing of simulations to kind of  like really illustrate that scaffolding concept and also the time element to have our students  master all those necessary building blocks or or competencies as we said. And of course, another  important element there is really constant checks of where they are, meaning assessments, right? And  therefore there's really a lot of discussions in nursing education right now about transitioning  to competency based education. Given your research on the importance of foundational  skills and gradual progression, how do you think your findings align with or contribute to this  ongoing conversation of concept based education in nursing? Yeah, I think that's a really important  question because with the push towards competency based education, you know there's a lot of focus  on designing the assessment and the evaluation to in to make sure that learners are meeting our  program outcomes. And as nurses I think our main focus is on what can  we do, how can we do it well, how can we get this problem attacked, right? But sometimes in our rush  to get those evaluations in place, we might lose sight a little bit of something that's kind of  critical - the learners themselves. We need to think deeply about what they find challenging,  what foundational skills do they need to master, and how can we guide them in learning how to think,  not just do. And in nursing education there's a, there's a push to prepare students for managing  highly complex patients before they graduate because patients are getting sicker in hospitals.  And I can definitely understand that point, but I don't know that  it's realistic to expect students to handle every possible scenario. What's more important is that we  provide them those foundational skills that they have hopefully mastered that can still develop as they're practicing and a lot of those skills, both physical skills and cognitive  skills, but if we focus on the core skills that then we can help students build confidence and  competence to, okay, I may not understand everything about this complex patient but I know how to do an  assessment, I know how to ask questions, I know how to think through is medication appropriate  or not, rather than just kind of pushing them into the deep end without having the essential thought  processes and skills to care for that complex patient. So if we think about it  in a care type situation, if we think about like a newly graduated nurse, would we expect them to take  over care for a post-op patient with we'll like design the most complicated patient ever. We'll  say they have a balloon pump and multiple drips and instability they are going up  and down in their stability and maybe sound, yeah, we'll throw in they're pregnant and preeclamptic  too. That is not a realistic patient. What we should really focus on is whether they've  mastered foundational skills to build toward that level of care. So can they take  take a thorough report, can they identify the most important cues and plan their assessment  accordingly, or do they understand why they're performing specific interventions and  what priorities they want to make. To me, mastering those foundational skills is key to learning how  to deal with a complex patient. Once we ensure that learners are secure those basics,  then they can apply skills and in a more logical type way to complex situations. So I just think  we might need to shift our concept of what we are working towards learners achieving. It's not really  about preparing them for the end evaluation. It's about teaching them the thought processes and clinical  reasoning that will get them there. So it's just rethinking how we define complexity because I  think we think of complexity in terms of like a scenario topic, but like even if we just take  medication for example. There are levels of complexity within medication. So complexity in medication could just be given a routine medicine versus a non-routine medicine,  different routes, whether it's appropriate for the patient's condition or not. We  can scaffold complexity within those basic foundational skills with all of it, really,  like no matter whether it's an assessment or order management, any of those things. We can  view complexity within the foundational skill. We don't have to make complexity mean they're  taking care of super complex patients in an inappropriate situation. So I really think we  can just restructure our thinking related to simulation experiences. It's not about passing  assessments or exposure to as many scenarios as possible. It's about creating opportunities  to practice, develop thinking, ensure mastery of foundational skills, and understanding the why.  And that's how we set students up for for success, not just in sims, but in the real world  too. Right, right. And hopefully as a profession or as a nursing education community we can  eventually kind of get united as to the end in point of what we want our students to achieve  eventually. And I think we're getting there. and I know that we can talk about this dear topic or  topic dear to our our heart on and on and on, but for now I would like you to I guess both of us, I  would like us to really kind of like take a pause, reflect some more, and really just push forward  with things that we need to kind of like implement in our daily practice as nurse educators. And thank  you so much for sharing your insights. This has been a thought-provoking conversation about the  importance of intentional simulation design and building foundational skills before tackling a  complex sim. Yeah, thank you so much for inviting me and thank you to the listeners for tuning in  to today's conversation. You know, I know shifting our thinking is never easy but I'm always proud to  be a part of a dedicated group of nurse educators who are just as committed to continuous growth and  success as we all want to be. So always remember, you know, it doesn't take too much complexity  to overwhelm learners. I appreciate this opportunity to be on this podcast. Yes, so I hope  that as nurse educators we continue to reflect on how we are designing our simulation experiences  and all other learning experiences in our curriculum and how we frame them in educational  theories, standards of practice and evidence. So bye for now and until our next episode.[Music]