Category Archives: Healthcare

Clinician Decision Making in Virtual Simulation

Oxygen placement virtual simulation
Oxygen placement virtual simulation

Healthcare professionals, like nurses, doctors, or occupational therapists, make an incredible number of decisions per day. In fact, nurses working in critical care actually make decisions almost every 30 seconds, adding up to about 960 decisions made in a single shift of work. 

This inordinate amount of decision-making directly impacts patient care, so it’s vital that clinicians are not only making and acting on these decisions, but also that they’re taking into account a multitude of factors given the context of the case to make the best possible decision for their patients. 

In order to build a skill, even complex and nuanced ones, repetition is a key component of success. Healthcare professionals and students alike need to continually leverage the knowledge they have to apply their skills and put it all together to make sound clinical decisions, and the use of new digital tools is one way to allow for consistent and flexible repetition to maintain or build skills. 

Clinical decision making

There are lots of terms used to describe a part of the whole process of making a clinical decision, and while they are all a piece of the puzzle, they’re not necessarily interchangeable. 

The term ‘clinical reasoning’, for example, was studied in a scoping review which found that across several hundred papers across health professions, 110 different terms were used to describe or to reference the concept of clinical reasoning. 

Within the context of physical or occupational therapies, there are explicit definitions in clear frameworks that use this term to describe the process of clinical reasoning, however, not all disciplines use the same definition or frameworks. 

‘Clinical judgment’ is a term becoming more quantifiable thanks to the National Council of State Boards of Nursing (NCSBN) who created a working model to measure clinical judgment in the Next Generation NCLEX. 

There are several models or frameworks used to describe the process of clinical decision making in nursing, and there are multiple factors that can influence the decision-maker, both intrinsic to the decision-maker, e.g. experience level, and extrinsic, i.e. environmental factors. 

virtual patient headache

Clinical decision making is context-dependent and often time-sensitive, meaning all of the factors that go into a decision and action require high-level cognitive skill to efficiently assess and analyze the entirety of the situation, then form a judgment, make a decision, and act. 

Methods like simulation-based education have been used to bolster the connection between theoretical knowledge and practice, and as virtual reality has been adopted into the healthcare industry, it’s gaining more traction in its use for the development and assessment of harder-to-test concepts like critical thinking, clinical reasoning, and clinical decision making. 

Virtual simulation supporting clinical decision making

Virtual simulation, often used as an umbrella term to include in-headset & immersive virtual reality (VR) and virtual screen-based simulation (VS) has become an accessible and flexible way to have learners work on skills and knowledge transfer in and outside of the classroom or clinical setting.

A systematic review spanning 1996-2018 found that 86% of included studies reported that virtual simulation had a positive effect on students’ learning outcomes, which included critical thinking and decision making, as well as knowledge and skill performance, among others.

For undergraduate nursing students, in particular, virtual simulation has been used to bolster the development of clinical decision making skills, and while more extensive research is needed in this rapidly-evolving field, virtual simulation appears to be promising for cognitive skill-building in future healthcare professionals.  

Virtual simulation offers a means by which learners can engage in simulation-based education at any time, anywhere, with unlimited opportunity to repeat and practice skills at their own pace.

virtual patient hand tremor

As virtual simulations are standardized, they’re able to be used to both practice conceptually-driven skills like clinical reasoning and for procedural skills like catheterization. 

By placing learners in a lead role, it’s easy to see how virtual simulation can encourage and challenge cognitive skills like clinical reasoning and judgment. 

In these scenarios, learners can assess the situation and gather relevant information through a variety of methods and use context-dependent reasoning and observational skills to inform hypotheses and implement interventions, without ever placing patient safety at risk. 

Learners are able to practice making decisions in a timely manner in a safe environment where mistakes are encouraged and used as a learning opportunity. 

Automated feedback can reinforce well-understood concepts and skills while providing evidence-based rationale to bolster acquired knowledge and bridge the gap for skills or concepts that prove difficult to transition to practice. 

In addition, virtual simulations can be used to assess these types of skills – University College Birmingham has utilized VR in this way with plans to expand its use in their programs, and Stamford Health has used VR to assist their entry-level nurses in the transition to practice. 

Virtual simulations continue to show promise for their use in the development of skills like clinical reasoning and decision making. To learn more about implementing VR into a curriculum or training program, set up a time to discuss in more detail here.

Interested in trying VR sim? Arrange a free demo with us today.

Understanding and Preparing for the Next Generation NCLEX

Laptop and VR headset on desk
Laptop and VR headset on desk

As of April 1st of this year, the Next Generation NCLEX (NGN) is in effect!

That means new item types, cascading questions, and greater emphasis on critical thinking and clinical decision making. 

These cascading questions involve a set of six questions, with a combination of different item types, that all relate to one case study. Test-takers will need to complete three of these case studies throughout the NGN, however, two will be scored while the third will be validated for future use. 

An exciting time for many in the nursing profession, both in clinical practice and in education, it’s also likely to be somewhat daunting for the first waves of test-takers. 

What is this new version of the NCLEX, and why should it be embraced, not feared? 

Why was the NCLEX updated? 

The National Council of State Boards of Nursing, or the NCSBN, noted the rising responsibilities of new nurses and the idea that they must make increasingly complex decisions during patient care. 

This points to the expectation for new nurses to utilize clinical judgment, which is a concept that encompasses both critical thinking and decision making skills.

What’s more is that recent data has shown concerning rates in terms of readiness to practice. Of those assessed, 91% of new nurses were outside of the acceptable range for competency. 

Another study reported that employers aren’t necessarily confident in their new nurses, either – in general, new nurses were viewed as underprepared to practice by their employers. 

Given the association between poor patient outcomes and poor clinical decision making, the need to properly assess clinical judgment as a criteria for licensure has become even more pronounced. 

Clearly, this concept of clinical judgment needed to be able to be reliably measured, and that’s one big reason why the Next Generation NCLEX was born. 

A closer look

Of course, measuring a broader concept like clinical judgment is no easy task. It’s much different than measuring knowledge like general anatomy where much of the material is memorized. 

Clinical judgment requires relevant knowledge and skills, and on top of that, it requires the cognitive ability to think critically and make decisions within the context of a given situation, sometimes in a very short period of time. 

Therefore, following much research and consultation, a model on clinical judgment measurement was created.

Unlike other models, the Clinical Judgment Measurement Model is multi-layered, and importantly, layer 3 holds the key components of clinical judgment – which are also measurable. 

They are: 

  • Recognizing cues
  • Analyzing cues
  • Prioritizing hypotheses
  • Generating solutions
  • Taking actions
  • Evaluating outcomes

Layer 4 is also an essential part of the equation, as it acknowledges the different internal and external factors that can influence decision making. 

Time pressures, task complexity, or distractions can impact how a decision is made, along with internal factors such as knowledge or experience level. 

Therefore, it’s important to measure layer 3 while understanding the nuance of layer 4. 

How are they measuring clinical judgment?

You’ve got an idea of the ‘why’ by now, but what about the ‘how’? 

This overview from the NCSBN details just how these processes were developed and how new item types came to be. 

There were numerous brainstorming sessions, writing panels, continuous review processes, drafts, rewrites, edits, and revisions, and ultimately, several new types of questions were decided on that ranged from the well-known to the brand new.

Classic item types like the standard multiple choice questions are still used. Other questions involve highlighting text or data, selecting all that apply, or selecting from multiple drop-down options. 

Many of these newer types of questions increase the possible number of answer combinations, placing more emphasis on clinical judgment and critical thinking.

However, it’s important to note that there is opportunity for partial credit on some, but not all, types of questions. For instance, a wrong answer for a multiple choice question has no opportunity for partial credit while a wrong choice in a select-all-that-apply question may garner partial points. 

These questions are often built upon one another, and several groupings may relate to one case, enhancing the realism of a written clinical situation. 

For a given case, the first question may require identification of relevant case information, and the next item requires interpretation of those findings. For example, a question may ask for the most concerning finding(s) or which finding(s) require follow up or continued assessment. 

As the case unfolds, new information will appear, requiring hypothesis generation and possible updating. These questions may ask about potential diagnoses or prioritization of problems.

Subsequent questions may ask about appropriate interventions and determination of the success of those actions. These types of questions revolve around the right types of interventions or medications, and understanding signs of worsening or bettering conditions. 

These types of cascading, related questions are meant to more closely reflect the realities of clinical practice and following a patient’s case throughout the course of their stay. 

How OMS can help in preparation

While clinical judgment is not a new concept, it is relatively new to being tested in a high-stakes, often pressure-intensive exam. 

As you or your learners apply knowledge to practice, simulation is a wonderful medium to engage critical thinking and decision making under time pressure while remaining in a psychologically safe environment. 

In-game screenshot of auscultation assessment

Sometimes making mistakes is an even better way to learn, which is why a safe space to do so is imperative in the learning process, especially as mistakes in simulation do not interfere with any patient safety. 

OMS scenarios are designed to challenge learners by placing them in the role of the nurse, making them responsible for the care of the patient, the delegation of tasks, and the implementation of appropriate courses of action. 

By taking on the lead role in-scenario, learners not only get a chance to put their skills into practice, but they also gain the opportunity to develop a sense of what their role truly entails. It’s very different to practice your skills when you know your clinical instructor is right there to answer any questions versus when you are completely on your own, making all of the decisions yourself. 

Learners must utilize the components of layer 3 of the Clinical Judgment Measurement Model in order to effectively complete the scenario.

In many OMS scenarios, cue recognition is essential for early intervention of a worsening acute condition. Learners must gather relevant information from the medical records and lab findings, and from the patient themselves, or a caregiver, if appropriate. 

Once all relevant data has been gathered, it is up to the learner to conduct assessments, interpret findings, and begin their hypothesis generation. 

In many instances, swift and efficient information collection and analysis is critical for nurses to identify problems, determine the right actions, and commence interventions. 

The authenticity of these scenarios mirrors actual clinical environments, embodying the inherent time constraints, distractions, and disruptions typically encountered throughout a shift. 

As new information becomes available, learners must remain adaptable in their thinking, continuously filtering information and updating their current hypotheses. 

For example, in OMS Multi-Patient scenarios, the learner may be interrupted in the middle of treating a patient with new information regarding a different patient, requiring attention, reprioritization, and delegation of tasks to accommodate it all in a timely manner and manage their caseload of multiple patients.

Once the learner performs an action, they must assess the outcome. That may require new orders or repeated testing, observational analysis, or patient and interdisciplinary communication. 

It is entirely up to the learner to take control of the situation, effectively care for the patient, and communicate with their team. 

After the scenario is concluded, learners are first required to complete a self-debrief, encouraging them to reflect on their experience prior to receiving any kind of feedback. The context of the scenarios themselves can also make for rich debriefing discussions, which are often conducted in small groups and facilitated by an experienced faculty member.

Feedback about how the learner led the scenario is automatically generated, providing time stamps of actions taken (or not taken), why those actions or concepts are important, and rationale is provided so learners can more deeply understand what went well and what needs to be improved. 

Tags appear alongside feedback that can align with many different types of exams, and for the NGN, there is a tag for clinical judgment.

Feedback with rationale on the 5 rights of medication administration

Learners can view which actions align with which pillars of the competency framework, providing clarity on what’s being assessed and how it all relates to practice. 

The measurement of clinical judgment by the Next Generation NCLEX is truly an exciting time to be a part of nursing education and practice, and OMS is ready to support you and your learners as you prepare for the transition to practice. 

To learn more about how OMS can support your learners, get in touch with us here

Interested in trying VR sim? Arrange a free demo with us today.

Can Virtual Simulation be used for Assessment?

person in headset holding laptop with VR simulation score
person in headset holding laptop with VR simulation score

When you think about using virtual simulation, you likely think about scenarios that learners go through to reinforce important concepts and to practice clinical skills. 

In many cases, you’re exactly right. Virtual reality has been used for some time in healthcare settings, particularly in education. 

As VR continues to grow, there are more and more possibilities for how it can be used, not just for skill-building and maintenance, but also as a tool for assessment.

What makes VR a good candidate for assessment?

Currently, VR simulations typically involve having a learner first orient to the equipment and context of the case, prepare as instructed, and take on the role of practitioner and run through the scenario.

Then, learners may receive feedback and get time to reflect, and in many cases, come together with a group of their peers and a facilitator to debrief on the case. 

With skill-building, repetition is key – which is one big difference between physical and virtual simulations. In VR, learners can repeat the scenario as many times as they need to feel comfortable and confident in their clinical skills, before ever being evaluated. 

Scenarios like those that OMS creates are based in best practices and current evidence. These VR simulations are standardized, and because of their consistency, there’s no need to worry about variability between raters.

Often in assessments, faculty are responsible for observing, taking notes, ensuring equipment or actors provide the right responses, and grading during an assessment. They are frequently expected to provide feedback and justification for the grade.

The objective nature of VR simulations, along with the automated, evidence-based feedback, frees up faculty from multitasking during evaluations and provides clear data and recommendations to the learner to improve their future performance.

feedback with rationale for SBAR

With VR, faculty can put their focus on the learner and let OMS do the rest – there are no worries about responses varying from one learner to the next, and faculty can instead be fully present in observing the learner, using their expertise to provide pointed feedback. 

For these reasons, among others, institutions are already seeing the benefits of implementing VR as a tool for assessment.  

How is it being used for assessment?

How it’s used depends largely on the facility, the learner level, and the key concepts and objectives being met. 

In other areas of healthcare, like emergency medicine, VR simulations have been used to assess clinical competence

Authors reported VR as a good tool in assessing both procedural skill and non-technical skills like communication, history taking, and clinical decision making.

They also reinforced the notion that in using VR, educators have a reduced cognitive load, particularly for case authoring. 

With a reduced likelihood of bias, as well as standardized scenarios with automated, evidence-based feedback, it’s no wonder why VR is arising as a valuable assessment tool for a wide range of clinical skills, both procedural and non-technical. 

What’s to come…

As VR continues to expand the possibilities for educators and trainers, there’s so much more to come from its use as an assessment tool.

You can use it to capture data that aligns directly with competency frameworks, like the NCLEX.

competency mapping & tracking NCLEX

As it can be difficult to write test questions that require multiple points of knowledge to answer, you’ll likely find you can use VR to assess higher-level thinking skills, like clinical reasoning and decision making. 

Learners are required to make effective decisions in real time, more closely resembling the realities of clinical practice. 

And because this all remains virtual, there is no fear of endangering others, which provides a layer of psychological safety, even in evaluation. 

With OMS, learners may have access to these simulations in their own time, meaning they can repeat these scenarios as many times as they need, without the need for faculty presence or supervision. 

To learn more about how you can use OMS as a learning and assessment tool, set up a time to chat with us here

Interested in trying VR sim? Arrange a free demo with us today.