A dimensional analysis of experienced intensive care unit nurses' clinical decision-making for bleeding after cardiac surgery.

BACKGROUND: Bleeding following cardiac surgery is common and serious, yet a gap persists in understanding how experienced intensive care nurses identify and respond to such complications. AIM: To describe the clinical decision-making of experienced intensive care unit nurses in addressing bleeding after cardiac surgery. STUDY DESIGN: This qualitative study adopted the Recognition-Primed Decision Model as its theoretical framework. Thirty-nine experienced nurses from four adult intensive care units participated in semi-structured interviews based on the critical decision method. The interviews explored their clinical judgements and decisions in bleeding situations, and data were analysed through dimensional analysis, an alternative to grounded theory. RESULTS: Participants maintained consistent vigilance towards post-cardiac surgery bleeding, recognizing it through a haemorrhagic dimension associated with blood loss and chest drainage and a hypovolemic dimension focusing on the repercussions of reduced blood volume. These dimensions organized their understanding of bleeding types (i.e., normal, medical, surgical, tamponade) and necessary actions. Their decision-making encompassed monitoring bleeding, identifying the cause, stopping the bleeding, stabilizing haemodynamic and supporting the patient and family. Participants also adapted their actions to specific circumstances, including local practices, professional autonomy, interprofessional dynamics and resource availability. CONCLUSIONS: Nurses' decision-making was shaped by their personal attributes, the patient's condition and contextual circumstances, underscoring their expertise and pivotal role in anticipating actions and adapting to diverse conditions. The concept of actionability emerged as the central dimension explaining their decision-making, defined as the capability to implement actions towards specific goals within the possibilities and constraints of a situation. RELEVANCE TO CLINICAL PRACTICE: This study underscores the need for continual updates to care protocols to align with current evidence and for quality improvement initiatives to close existing practice gaps. Exploring the concept of actionability further, developing adaptability-focused educational programmes, and understanding decision-making intricacies are crucial for informing nursing education and decision-support systems.

Development and Contribution of a Serious Game to Improve Nursing Students' Clinical Reasoning in Acute Heart Failure: A Multimethod Study.

Clinical reasoning is essential for nurses and nursing students to recognize and intervene when hospitalized patients present acute heart failure. Serious games are digital educational interventions that could foster the development of clinical reasoning through an engaging and intrinsically motivating learning experience. However, elements from a playful approach (eg, rewards, narrative elements) are often absent or poorly integrated in existing serious games, which may limit their contribution to learning. Thus, we developed and studied the contribution of a novel serious game on nursing students' engagement, intrinsic motivation, and clinical reasoning in the context of acute heart failure. We adopted a multimethod design and randomized 28 participants to receive two serious game prototypes in a different sequence, one that fully integrated elements of a playful approach (SIGN@L-A) and one that offered only objectives, feedback, and a functional aesthetic (SIGN@L-B). Through self-reported questionnaires, participants reported higher levels of engagement and intrinsic motivation after using SIGN@L-A. However, negligible differences in clinical reasoning scores were found after using each serious game prototype. During interviews, participants reported on the contribution of design elements to their learning. Quantitative findings should be replicated in larger samples. Qualitative findings may guide the development of future serious games.

Evolution of burnout and psychological distress in healthcare workers during the COVID-19 pandemic: a 1-year observational study.

BACKGROUND: Long-term psychological impacts of the COVID-19 pandemic on healthcare workers remain unknown. We aimed to determine the one-year progression of burnout and mental health since pandemic onset, and verify if protective factors against psychological distress at the beginning of the COVID-19 pandemic (Cyr et al. in Front Psychiatry; 2021) remained associated when assessed several months later. METHODS: We used validated questionnaires (Maslach Burnout Inventory, Hospital Anxiety and Depression and posttraumatic stress disorder [PTSD] Checklist for DSM-5 scales) to assess burnout and psychological distress in 410 healthcare workers from Quebec, Canada, at three and 12 months after pandemic onset. We then performed multivariable regression analyses to identify protective factors of burnout and mental health at 12 months. As the equivalent regression analyses at three months post-pandemic onset had already been conducted in the previous paper, we could compare the protective factors at both time points. RESULTS: Prevalence of burnout and anxiety were similar at three and 12 months (52% vs. 51%, p = 0.66; 23% vs. 23%, p = 0.91), while PTSD (23% vs. 11%, p < 0.0001) and depression (11% vs. 6%, p = 0.001) decreased significantly over time. Higher resilience was associated with a lower probability of all outcomes at both time points. Perceived organizational support remained significantly associated with a reduced risk of burnout at 12 months. Social support emerged as a protective factor against burnout at 12 months and persisted over time for studied PTSD, anxiety, and depression. CONCLUSIONS: Healthcare workers' occupational and mental health stabilized or improved between three and 12 months after the pandemic onset. The predominant protective factors against burnout remained resilience and perceived organizational support. For PTSD, anxiety and depression, resilience and social support were important factors over time.

Designing, planning, and conducting systematic reviews and other knowledge syntheses: Six key practical recommendations to improve feasibility and efficiency.

BACKGROUND: Knowledge syntheses, such as systematic reviews, scoping reviews, and realist reviews, are crucial tools to guide nursing practice, policy, and research. However, conducting high-quality knowledge syntheses is a complex and time-consuming endeavor. It is imperative for nursing students, clinicians, and researchers to be aware of key practical recommendations regarding the conduct of knowledge syntheses to improve the feasibility and efficiency of such projects. AIM: The aim of this paper was to discuss key practical recommendations for designing, planning, and conducting knowledge syntheses relevant to nursing policy, practice, and research. METHODS: The recommendations discussed are based on best-practice guidance about knowledge synthesis methodology proposed by The Campbell Collaboration (Campbell systematic reviews: Policies and guidelines, 2020), Cochrane (Cochrane training, 2019), and the Joanna Briggs Institute (The Joanna Briggs Institute reviewers' manual, 2020) and on strategies used by the authors to improve the feasibility and efficiency of knowledge syntheses. RESULTS: This paper highlights six key practical recommendations that nursing students, clinicians, and researchers should take into account when deciding to embark on a knowledge synthesis project: (1) determining if (and why) knowledge synthesis should be conducted; (2) selecting the appropriate type of knowledge synthesis, as well as the associated methodological guidance and reporting standards; (3) developing a search strategy that balances sensitivity and specificity; (4) writing a protocol and obtaining feedback; (5) determining the resources required to conduct the different stages of the knowledge synthesis; and (6) keeping an audit trail. Fifteen common types of knowledge synthesis are presented with their definitions, relevant methodological guidance, and reporting standards. LINKING EVIDENCE TO ACTION: The recommendations discussed, used in conjunction with appropriate methodological guidelines, may help ensure the success of a knowledge synthesis project by providing best-practice and experience-based guidance to newcomers in the field.

A stress-induced block in dicarboxylate uptake and utilization in Salmonella.

Bacteria have evolved to sense and respond to their environment by altering gene expression and metabolism to promote growth and survival. In this work we demonstrate that Salmonella displays an extensive (>30 hour) lag in growth when subcultured into media where dicarboxylates such as succinate are the sole carbon source. This growth lag is regulated in part by RpoS, the RssB anti-adaptor IraP, translation elongation factor P, and to a lesser degree the stringent response. We also show that small amounts of proline or citrate can trigger early growth in succinate media and that, at least for proline, this effect requires the multifunctional enzyme/regulator PutA. We demonstrate that activation of RpoS results in the repression of dctA, encoding the primary dicarboxylate importer, and that constitutive expression of dctA induced growth. This dicarboxylate growth lag phenotype is far more severe across multiple Salmonella isolates than in its close relative E. coli Replacing 200 nt of the Salmonella dctA promoter region with that of E. coli was sufficient to eliminate the observed lag in growth. We hypothesized that this cis-regulatory divergence might be an adaptation to Salmonella's virulent lifestyle where levels of phagocyte-produced succinate increase in response to bacterial LPS, however we found that impairing dctA repression had no effect on Salmonella's survival in acidified succinate or in macrophages.Importance Bacteria have evolved to sense and respond to their environment to maximize their chance of survival. By studying differences in the responses of pathogenic bacteria and closely related non-pathogens, we can gain insight into what environments they encounter inside of an infected host. Here we demonstrate that Salmonella diverges from its close relative E. coli in its response to dicarboxylates such as the metabolite succinate. We show that this is regulated by stress response proteins and ultimately can be attributed to Salmonella repressing its import of dicarboxylates. Understanding this phenomenon may reveal a novel aspect of the Salmonella virulence cycle, and our characterization of its regulation yields a number of mutant strains that can be used to further study it.

Integrating equity and social justice for indigenous peoples in undergraduate health professions education in Canada: a framework from a critical review of literature.

Understanding how to create structural change by actively counteracting racialized ways of interacting with Indigenous peoples at an individual and organizational level within health care systems and health professions education is essential for creating a more inclusive, equitable, and healthier society. In health professions education, the primary means of teaching about health inequities has been to frame them as stemming from culturally or ethnically based issues. While attention to culturally specific practices can be valuable to health and healing in some contexts, education that solely focuses on Indigenous cultures risks perpetuating cultural stereotypes and othering, rather than focusing on how Eurocentric systems continue to exert oppressive effects on Indigenous peoples. We present an organizational transformation framework grounded in equitable partnerships from a comprehensive critical review of the literature on the integration of equity and social justice in undergraduate health professions education with a focus on Indigenous health. We did a thematic analysis of the results and discussions presented in the 26 selected articles to identify promising practices and challenges associated with the integration of equity and social justice in undergraduate health professions education. The framework resulting from this analysis is composed of three interrelated components: 1) adopt critical pedagogical approaches that promote Indigenous epistemologies; 2) partner with Indigenous students, educators and communities; 3) engage educators in critical pedagogical approaches and health equity issues. This framework could guide the development of contextually tailored interventions that contribute to decolonizing health professions education.

Nurses' experience of handoffs on four Canadian medical and surgical units: A shared accountability for knowing and safeguarding the patient.

AIMS: To explore nurses' experience and describe how they manage various contextual factors affecting the nurse-to-nurse handoff at change of shift. DESIGN: Qualitative descriptive study. METHODS: A convenience sample of 51 nurses from four medical and surgical care units at a university-affiliated hospital in Montreal, Canada, participated in one of the 19 focus group interviews from November 2017 to January 2018. Data were analysed through a continuous and iterative process of thematic analysis. RESULTS: Analysis of the data generated a core theme of 'sharing accountability for knowing and safeguarding the patient' that is achieved through actions related to nurses' role in the exchange. Specifically, the outgoing nurse takes actions to ensure continuity of care when letting go, and the incoming nurse takes actions to provide seamless care when taking over. In both roles, nurses navigate each handoff juncture by mutually adjusting, ensuring attentiveness, managing judgements, keeping on track, and venting and debriefing. Handoff is also shaped by contextual conditions related to handoff norms and practices, the nursing environment, individual nurse attributes and patient characteristics. CONCLUSIONS: This study generated a conceptualization of nurses' roles and experience that details the relationship among the elements and conditions that shape nurse-to-nurse handoffs. IMPACT: Nursing handoff involves the communication of patient information and relational behaviours that support the exchange. Although many factors are known to influence handoffs, little was known about nurses' experience of dealing with these at the point of care. This study contributed a comprehensive conceptualization of nursing handoff that could be useful in identifying areas for quality improvement and guiding future educational efforts.

A conceptual framework of student professionalization for health professional education and research.

OBJECTIVES: To present a conceptual framework of student professionalization for health professional education and research. METHODS: Synthesis and discussion of a program of research on competency-based education. RESULTS: Competency-based education relies on active, situation-based group learning strategies to prepare students to become health professionals who are connected to patient and population needs. Professionalization is understood as a dynamic process of imagining, becoming, and being a member of a health profession. It rests on the evolution of three interrelated dimensions: professional competencies, professional culture, and professional identity. Professionalization occurs throughout students' encounters with meaningful learning experiences that involve three core components: the roles students experience in situations bounded within specific contexts. Educational practices conducive to professionalization include active learning, reflection, and feedback. CONCLUSIONS: This conceptual framework drives a research agenda aimed at understanding how students become health professional and how learning experiences involving action, reflection, and feedback foster that process and the advancement of professional practices.

New graduate nurses' clinical competence: A mixed methods systematic review.

AIM: To appraise and synthesize evidence of empirical studies reporting assessment of new graduate nurses' clinical competence in clinical settings. DESIGN: Mixed methods systematic review. DATA SOURCES: The search strategy included keywords relevant to: new graduate nurse; clinical competence; and competence assessment. The searched literature databases included CINAHL, MEDLINE, Embase, PsycINFO and Web of Science. The search was limited to full-text papers in English or French, published between 2010 -September 2019. REVIEW METHODS: Inclusion criteria were: 1) empirical studies; 2) detailed method and complete results sections; 3) competence assessment in clinical settings; and 4) new graduate nurses (≤24 months). Two independent reviewers screened eligible papers, extracted data and used the Mixed Methods Appraisal Tool framework for quality appraisal. Divergences were solved through discussion. RESULTS: About 42 papers were included in this review: quantitative (N = 31), qualitative (N = 7) and mixed methods (N = 4). Findings suggest that new graduate nurses exhibit a good or adequate level of competence. Longitudinal studies show a significant increase in competence from 0-6 months, but findings are inconsistent from 6-12 months. CONCLUSION: There are a multitude of quantitative tools available to measure clinical competence. This suggests a need for a review of their rigor. IMPACT: No recent reviews comprehensively synthesized the findings from new graduate nurses' clinical competence. This review has found that new graduate nurses' competence has been mostly assessed as good, despite the expectation that they should be more competent. Longitudinal studies did not always show a significant increase in competence. These findings can help nurse educators in providing more support to new graduate nurses throughout the transition period or design improved transition programme. This review also identified quantitative tools and qualitative methods that can be used for competence assessment.

Nursing handoffs and clinical judgments regarding patient risk of deterioration: A mixed-methods study.

AIMS AND OBJECTIVES: To explore how change-of-shift handoffs relate to nurses' clinical judgments regarding patient risk of deterioration. BACKGROUND: The transfer of responsibility for patients' care comes with an exchange of information about their condition during change-of-shift handoff. However, it is unclear how this exchange affects nurses' clinical judgments regarding patient risk of deterioration. DESIGN: A sequential explanatory mixed-methods study reported according to the STROBE and COREQ guidelines. METHODS: Over four months, 62 nurses from one surgical and two medical units at a single Canadian hospital recorded their handoffs at change of shift. After each handoff, the two nurses involved each rated the patient's risk of experiencing cardiac arrest or being transferred to an intensive care unit in the next 24 hr separately. The information shared in handoffs was subjected to content analysis; code frequencies were contrasted per nurses' ratings of patient risk to identify characteristics of information that facilitated or hindered nurses' agreement. RESULTS: Out of 444 recorded handoffs, there were 125 in which at least one nurse judged that a patient was at risk of deterioration; nurses agreed in 32 cases (25.6%) and disagreed in 93 (74.4%). These handoffs generally included information on abnormal vital signs, breathing problems, chest pain, alteration of mental status or neurological symptoms. However, the quantity and seriousness of clinical cues, recent transfers from intensive care units, pain without a clear cause, signs of delirium and nurses' knowledge of patient were found to affect nurses' agreement. CONCLUSIONS: Nurses exchanged more information regarding known indicators of deterioration in handoffs when they judged that patients were at risk. Disagreements most often involved incoming nurses rating patient risk as higher. RELEVANCE TO CLINICAL PRACTICE: This study suggests a need to sensitise nurses to the impact of certain cues at report on their colleagues' subsequent clinical judgments. Low levels of agreement between nurses underscore the importance of exchanging impressions regarding the likely evolution of a patient's situation to promote continuity of care.

Perceptions of Emergency Medicine Residents of Multisource Feedback: Different, Relevant, and Useful Information.

STUDY OBJECTIVE: Multisource feedback is a process through which different members of the care team assess and provide feedback on residents' competencies, usually those that are less often addressed by traditional assessment methods (ie, communication, collaboration, and professionalism). Feasibility and reliability of multisource feedback have been addressed in previous research. The present study explores emergency residents' perceptions of multisource feedback provided by teaching physicians, nurses, and patients they have worked with during a rotation in an emergency department (ED). METHODS: A multisource feedback intervention was proposed to residents during 9 months in the ED of a tertiary care university hospital. Residents distributed feedback questionnaires to physicians, nurses, and patients that focused on competencies (collaboration, communication, and professionalism) from the CanMEDS framework. Responses were compiled and reported to participating residents. To assess residents' perceptions of multisource feedback, semistructured group and individual interviews were held 3 months after the intervention. Transcripts were analyzed qualitatively, following Miles and Huberman's method for intrasite case analysis. RESULTS: According to residents (n=10), each source (physicians, nurses, and patients) provided relevant comments that differed significantly in their content. Physicians focused primarily on medical expertise; nurses addressed competencies related to leadership, collaboration, and communication; and patients commented on the competencies of professionalism and communication. Residents concluded that obtaining feedback from nurses and patients was acceptable and useful. They reported modifying certain behaviors after receiving the multisource feedback. CONCLUSION: Residents perceived the multisource feedback to be acceptable and useful for the assessment of medical competencies such as communication, collaboration, professionalism, and leadership.

Using a Wireless Electroencephalography Device to Evaluate E-Health and E-Learning Interventions.

BACKGROUND: Measuring engagement and other reactions of patients and health professionals to e-health and e-learning interventions remains a challenge for researchers. OBJECTIVE: The aim of this pilot study was to assess the feasibility and acceptability of using a wireless electroencephalography (EEG) device to measure affective (anxiety, enjoyment, relaxation) and cognitive (attention, engagement, interest) reactions of patients and healthcare professionals during e-health or e-learning interventions. METHODS: Using a wireless EEG device, we measured patient (n = 6) and health professional (n = 7) reactions during a 10-minute session of an e-health or e-learning intervention. The following feasibility and acceptability indicators were assessed and compared for patients and healthcare professionals: number of eligible participants who consented to participate, reasons for refusal, time to install and calibrate the wireless EEG device, number of participants who completed the full 10-minute sessions, participant comfort when wearing the device, signal quality, and number of observations obtained for each reaction. The wireless EEG readings were compared to participant self-rating of their reactions. RESULTS: We obtained at least 75% of possible observations for attention, engagement, enjoyment, and interest. EEG scores were similar to self-reported scores, but they varied throughout the sessions, which gave information on participants' real-time reactions to the e-health/e-learning interventions. Results on the other indicators support the feasibility and acceptability of the wireless EEG device for both patients and professionals. DISCUSSION: Using the wireless EEG device was feasible and acceptable. Future studies must examine its use in other contexts of care and explore which components of the interventions affected participant reactions by combining wireless EEG and eye tracking.

Learning theories and tools for the assessment of core nursing competencies in simulation: A theoretical review.

AIM: To identify the theories used to explain learning in simulation and to examine how these theories guided the assessment of learning outcomes related to core competencies in undergraduate nursing students. BACKGROUND: Nurse educators face the challenge of making explicit the outcomes of competency-based education, especially when competencies are conceptualized as holistic and context dependent. DESIGN: Theoretical review. DATA SOURCES: Research papers (N = 182) published between 1999-2015 describing simulation in nursing education. REVIEW METHODS: Two members of the research team extracted data from the papers, including theories used to explain how simulation could engender learning and tools used to assess simulation outcomes. Contingency tables were created to examine the associations between theories, outcomes and tools. RESULTS: Some papers (N = 79) did not provide an explicit theory. The 103 remaining papers identified one or more learning or teaching theories; the most frequent were the National League for Nursing/Jeffries Simulation Framework, Kolb's theory of experiential learning and Bandura's social cognitive theory and concept of self-efficacy. Students' perceptions of simulation, knowledge and self-confidence were the most frequently assessed, mainly via scales designed for the study where they were used. Core competencies were mostly assessed with an observational approach. CONCLUSION: This review highlighted the fact that few studies examined the use of simulation in nursing education through learning theories and via assessment of core competencies. It also identified observational tools used to assess competencies in action, as holistic and context-dependent constructs.

Polarization-Resolved Raman Study of Bulk-like and Davydov-Induced Vibrational Modes of Exfoliated Black Phosphorus.

Owing to its crystallographic structure, black phosphorus is one of the few 2D materials expressing strongly anisotropic optical, transport, and mechanical properties. We report on the anisotropy of electron-phonon interactions through a polarization-resolved Raman study of the four vibrational modes of atomically thin black phosphorus (2D phosphane): the three bulk-like modes Ag1, B2g, and Ag2 and the Davydov-induced mode labeled Ag(B2u). The complex Raman tensor elements reveal that the relative variation in permittivity of all Ag modes is irrespective of the atomic motion involved lowest along the zigzag direction, the basal anisotropy of these variations is most pronounced for Ag2 and Ag(B2u), and interlayer interactions in multilayer samples lead to reduced anisotropy. The bulk-forbidden Ag(B2u) mode appears for n ≥ 2 and quickly subsides in thicker layers. It is assigned to a Davydov-induced IR to Raman conversion of the bulk IR mode B2u and exhibits characteristics similar to Ag2. Although this mode is expected to be weak, an electronic resonance significantly enhances its Raman efficiency such that it becomes a dominant mode in the spectrum of bilayer 2D phosphane.

Defining patient deterioration through acute care and intensive care nurses' perspectives.

AIM: To explore the variations between acute care and intensive care nurses' understanding of patient deterioration according to their use of this term in published literature. BACKGROUND: Evidence suggests that nurses on wards do not always recognize and act upon patient deterioration appropriately. Even if resources exist to call for intensive care nurses' help, acute care nurses use them infrequently and the problem of unattended patient deterioration remains. DESIGN: Dimensional analysis was used as a framework to analyze papers retrieved in a nursing-focused database. METHOD: A thematic analysis of 34 papers (2002-2012) depicting acute care and intensive care unit nurses' perspectives on patient deterioration was conducted. FINDINGS: No explicit definition of patient deterioration was retrieved in the papers. There are variations between acute care and intensive care unit nurses' accounts of this concept, particularly regarding the validity of patient deterioration indicators. Contextual factors, processes and consequences are also explored. CONCLUSIONS: From the perspectives of acute care and intensive care nurses, patient deterioration can be defined as an evolving, predictable and symptomatic process of worsening physiology towards critical illness. Contextual factors relating to acute care units (ACU) appear as barriers to optimal care of the deteriorating patient. This work can be considered as a first effort in modelling the concept of patient deterioration, which could be specific to ACU. RELEVANCE TO CLINICAL PRACTICE: The findings suggest that it might be relevant to include subjective indicators of patient deterioration in track and trigger systems and educational efforts. Contextual factors impacting care for the deteriorating patient could be addressed in further attempts to deal with this issue.

Investigating clinical decision-making in bleeding complications among nursing students: A longitudinal mixed-methods study.

AIM: To describe undergraduate nursing students' clinical decision-making in post-procedural bleeding scenarios and explore the changes from the first to the final year of their program. BACKGROUND: Bleeding is a common complication following invasive procedures and its effective management requires nurses to develop strong clinical decision-making competencies. Although nursing education programs typically address bleeding complications, there is a gap in understanding how nursing students make clinical decisions regarding these scenarios. Additionally, little is known about how their approach to bleeding management evolves over the course of their education. DESIGN: Longitudinal mixed-methods study based on the Recognition-Primed Decision Model. METHODS: A total of 59 undergraduate students recorded their responses to two clinical decision-making vignettes depicting patients with signs of bleeding post-hip surgery (first year) and cardiac catheterization (final year). Their responses were analyzed using content analysis. The resulting categories capture the cues students noticed, the goals they aimed to achieve, the actions they proposed and their expectations for how the bleeding situations might unfold. Code frequencies showing the most variation between the first and final years were analyzed to explore changes in students' clinical decision-making. RESULTS: Nearly all students focused on two primary categories: 'Bleeding' and 'Instability and Shock.' Fewer students addressed six secondary categories: 'Stress and Concern,' 'Pain,' 'Lifestyle and Social History,' 'Wound Infection,' 'Arrhythmia,' and 'Generalities in Surgery.' Students often concentrated on actions to manage bleeding without further assessing its causes. Changes from the first to the final year included a more focused assessment of instability and shifts in preferred actions. CONCLUSIONS: This study reveals that nursing students often prioritize immediate actions to stop bleeding while sometimes overlooking the assessment of underlying causes or broader care goals. It suggests that concept-based learning and reflection on long-term outcomes could improve clinical decision-making in post-procedural care.

Current practices for assessing clinical judgment in nursing students and new graduates: A scoping review.

OBJECTIVE: To map current assessment practices for learning outcomes related to nurses' clinical judgment from undergraduate education to entry to practice. DESIGN: Scoping review using the Joanna Briggs Institute guidelines and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). DATA SOURCES: Electronic databases-Cumulative Index of Nursing and Allied Health Literature (CINAHL Complete; EBSCOhost), EMBASE (Ovid), MEDLINE (Ovid), PsycINFO (Ovid), and Web of Science (Social Sciences Citation Index, Citation Index Expanded)-using a combination of descriptors and keywords related to nursing students, newly graduated nurses, clinical judgment and related terms (e.g., critical thinking, clinical reasoning, clinical decision-making, and problem-solving), and assessment. METHODS: Two reviewers independently extracted study characteristics and, for each outcome relevant to clinical judgment, the concept, definition and framework, assessment tool, and the number and schedule of assessments. Data were synthesized narratively and using descriptive statistics. RESULTS: Most of the 52 reviewed studies examined the outcome of a discrete educational intervention (76.9 %) in academic settings (78.8 %). Only six studies (11.5 %) involved newly graduated nurses. Clinical judgment (34.6 %), critical thinking (26.9 %), and clinical reasoning (9.6 %) were the three most frequent concepts. Three assessment tools were used in more than one study: the Lasater Clinical Judgment Rubric (n = 22, 42.3 %), the California Critical Thinking Skills Test (n = 9, 17.3 %), and the Health Science Reasoning Test (n = 2, 3.8 %). Eleven studies (21.2 %) used assessment tools designed for the study. CONCLUSION: In addition to a disparate understanding of underlying concepts, there are minimal published studies on the assessment of nursing students and nurses' clinical judgment, especially for longitudinal assessment from education to clinical practice. Although there is some existing research on this topic, further studies are necessary to establish valid and reliable clinical competency assessment methods that effectively integrate clinical judgment in clinical situations at relevant time points.

Effects of implementation strategies on nursing practice and patient outcomes: a comprehensive systematic review and meta-analysis.

BACKGROUND: Implementation strategies targeting individual healthcare professionals and teams, such as audit and feedback, educational meetings, opinion leaders, and reminders, have demonstrated potential in promoting evidence-based nursing practice. This systematic review examined the effects of the 19 Cochrane Effective Practice and Organization Care (EPOC) healthcare professional-level implementation strategies on nursing practice and patient outcomes. METHODS: A systematic review was conducted following the Cochrane Handbook, with six databases searched up to February 2023 for randomized studies and non-randomized controlled studies evaluating the effects of EPOC implementation strategies on nursing practice. Study selection and data extraction were performed in Covidence. Random-effects meta-analyses were conducted in RevMan, while studies not eligible for meta-analysis were synthesized narratively based on the direction of effects. The quality of evidence was assessed using GRADE. RESULTS: Out of 21,571 unique records, 204 studies (152 randomized, 52 controlled, non-randomized) enrolling 36,544 nurses and 340,320 patients were included. Common strategies (> 10% of studies) were educational meetings, educational materials, guidelines, reminders, audit and feedback, tailored interventions, educational outreach, and opinion leaders. Implementation strategies as a whole improved clinical practice outcomes compared to no active intervention, despite high heterogeneity. Group and individual education, patient-mediated interventions, reminders, tailored interventions and opinion leaders had statistically significant effects on clinical practice outcomes. Individual education improved nurses' attitude, knowledge, perceived control, and skills, while group education also influenced perceived social norms. Although meta-analyses indicate a small, non-statistically significant effect of multifaceted versus single strategies on clinical practice, the narrative synthesis of non-meta-analyzed studies shows favorable outcomes in all studies comparing multifaceted versus single strategies. Group and individual education, as well as tailored interventions, had statistically significant effects on patient outcomes. CONCLUSIONS: Multiple types of implementation strategies may enhance evidence-based nursing practice, though effects vary due to strategy complexity, contextual factors, and variability in outcome measurement. Some evidence suggests that multifaceted strategies are more effective than single component strategies. Effects on patient outcomes are modest. Healthcare organizations and implementation practitioners may consider employing multifaceted, tailored strategies to address local barriers, expand the use of underutilized strategies, and assess the long-term impact of strategies on nursing practice and patient outcomes. TRIAL REGISTRATION: PROSPERO CRD42019130446.

Reflective debriefing to promote novice nurses' clinical judgment after high-fidelity clinical simulation: a pilot test.

BACKGROUND: Novice nurses are increasingly beginning their career paths in critical care areas, where they are expected to care for patients whose lives are potentially threatened. They are unable to benefit from years of experience to facilitate their clinical decisions. Reflection after simulation could possibly improve nurses' clinical judgment in complex situations. DESIGN: An educational project was conducted to pilot-test a teaching intervention, which combined reflective debriefing with a simulated critical care experience. METHOD: Five nurses beginning in an intensive care unit participated in the pilot test. Their perception of their learning and satisfaction with the reflective debriefing and the simulation were collected using open-ended questionnaires. A clinical nurse educator, a faculty member and the first author participated in a group discussion to review the time plan and the affective components of the teaching intervention. RESULTS: Participants reported that the reflective debriefing helped them understand their cognitive processes during the simulation and contributed to clinical judgment development and to their care prioritization and assessment capacities. Observers reported the time plan was adequate and that attention to participants' negative feelings was necessary. CONCLUSION: The results of this pilot test provide preliminary information that reflective debriefing may be a safe and potentially effective way for novice critical care nurses to learn from a clinical experience and enhance clinical judgment.