The Impact of Critical Thinking upon Clinical Judgment ...· The Impact of Critical Thinking upon

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The Impact of Critical Thinking upon Clinical

Judgment during Simulation with Senior

Nursing Students Mary Cazzell, RN, PhD

Mindi Anderson, PhD, RN, CPNP-C, CNE, CHSE-A, ANEF


Funding for this study:

2012 NLN Foundation for Nursing Education Fund

Kathie Lasater, EdD, RN, ANEF

Carol Howe, RN, MSN, PhD(c)


Confusion among nurse educators regarding which high quality student outcomes to facilitate in didactic, clinical, and simulation settings: Critical thinking

Clinical reasoning

Clinical judgment


Examine the impact of components of critical thinking upon clinical judgment during a pediatric medication administration OSCE with senior-level nursing students


Challenge: Radical transformation of nursing education (Benner, Sutphen, Leonard, & Day, 2010)

Numerous interchangeable and overlapping definitions

Profetto-McGrath (2003): critical thinking: process of logical reasoning with prudent judgment

Pesut & Herman (1999): clinical reasoning: process of critical thinking, reflection, and creativity used to make judgments

Theoretical Framework

1. Clinical Judgment Model (Tanner, 2006) a) Noticing

b) Interpreting

c) Responding

d) Reflecting

e) Lasater Clinical Judgment Rubric (Lasater, 2007)

2. Neurodevelopment of critical thinking (McAnarney, 2008; Steinberg, 2008)

Guided choice of independent study variables



Convenience sample

160 Senior 1 pre-licensure baccalaureate

nursing students

Fall 2012 and Spring 2013 semesters

University ranks in nations top 10% for

racial diversity

Research Design

Quantitative descriptive correlational study

Methods: Independent Variables

Study Measures:

1. Student Demographic Survey

2. Tower of Hanoi (Welsh & Huizinga, 2001)

3. Health Science Reasoning Test (Insight Assessment, 2011)

Methods: Dependent Variable

Pediatric Medication Administration OSCE

Videotaped performances scored

Lasater Clinical Judgment Rubric

11-items based on Tanner (2006) model

Perfect score = 44 points

4 dimensions of effectiveness





Results: Demographic Data

85% female

Median age: 23 years (Range 20-62 yrs)


42% Caucasian

25% Asian

16% Hispanic

11% African American

GPAs: 2.5-3.0 (46%) & 3.0-3.5 (43%)

49%: previous healthcare experience

Results: TOH & HSRT

Tower of Hanoi:

Average 7 moves over minimum/task

Did better in earlier easier vs. later more complex tasks

>70% required 1-15 moves in Tasks 11-15

Health Science Reasoning Test

Average score: 25.31 (out of total 38)

Induction highest scores (7.26)

Inference lowest scores (2.90)

Results: Lasater Clinical Judgment Rubric

Total scores: 30.74 (SD 2.41)

Out of possible 44 points

Noticing: 8.60 (SD 1.07)

Out of possible 12 points

Interpreting: 5.98 (SD 0.17)

Out of possible 8 points

Responding: 10.41 (SD 1.52)

Out of possible 16 points

Reflecting: 5.77 (SD 0.77)

Out of possible 8 points

Results: Regression Analyses

4 critical thinking variables predicted clinical judgment

1. Gender: females scored higher than males

2. Ethnicity: African Americans had significantly lower scores on LCJR

3. HSRT deduction score: higher score predicted higher LCJR score

4. HSRT analysis score: higher score predicted lower LCJR score

Implications for Nurse Educators

Critical thinking and clinical judgment:

Need separate concise definitions

Small overlap between components

Develop innovative teaching strategies to address predictors of clinical judgment

Attention to gender and ethnicity


Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco: Jossey-Bass.

Insight Assessment. (2011). Research: Health sciences and critical thinking. Retrieved from

Lasater, K. (2007). Clinical judgment development: Using simulation to create a rubric. Journal of Nursing Education, 46,496-503.

McAnarney, E. R. (2008). Adolescent brain development: Forging new links. Journal of Adolescent Health, 42, 321-323.

Pesut, D. J. & Herman, J. (1999). Clinical reasoning: The art and science of critical and creative thinking. Albany, NY: Delmar Publishers.


Profetto-McGrath, J. (2003). The relationship of critical thinking skills and critical thinking dispositions of baccalaureate nursing students. Journal of Advanced Nursing, 43(6), 569-577.

Steinberg, L. (2008). A social neuroscience perspective on adolescent risk-taking. Developmental Review, 28, 78-106.

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment. Journal of Nursing Education, 45, 204-211.

Welsh, M. C. & Huizinga, M. (2001). The development and preliminary validation of the Tower of Hanoi-Revised. Assessment, 8(2), 167-176.