WEBVTT 00:00:05.410 --> 00:00:06.540 position:50% align:middle Good afternoon. 00:00:06.540 --> 00:00:09.610 position:50% align:middle As Brandon mentioned, my name is Nicole Williams. 00:00:09.610 --> 00:00:13.747 position:50% align:middle I'm the associate director of examinations at NCSBN. 00:00:13.747 --> 00:00:17.370 position:50% align:middle I've been a nurse for a little bit over 30 years. 00:00:17.370 --> 00:00:18.933 position:50% align:middle I started when I was 15. 00:00:18.933 --> 00:00:21.180 position:50% align:middle That's my story, and I'm sticking to it. 00:00:21.180 --> 00:00:28.380 position:50% align:middle So, unsurprisingly, my interest has been in entry-level nursing for the last, 00:00:28.380 --> 00:00:31.920 position:50% align:middle probably about 14 years since joining NCLEX. 00:00:31.920 --> 00:00:39.750 position:50% align:middle Prior to joining NCLEX, I imagine that the exam was developed by four retired 00:00:39.750 --> 00:00:45.610 position:50% align:middle educators who were just in a closet somewhere writing questions just to stick it to the students. 00:00:45.610 --> 00:00:48.670 position:50% align:middle But it's absolutely so much more than that. 00:00:48.670 --> 00:00:54.970 position:50% align:middle And I think we certainly have realized how much more it is just recently as we've added clinical judgment 00:00:54.970 --> 00:00:57.020 position:50% align:middle to the NCLEX. 00:00:57.020 --> 00:01:03.030 position:50% align:middle One of the things that we continue to do with our research program on the examination side is we continue 00:01:03.030 --> 00:01:09.960 position:50% align:middle to examine clinical judgment and its intersection between clinical practice of entry-level nurses 00:01:09.960 --> 00:01:11.950 position:50% align:middle and our assessment. 00:01:11.950 --> 00:01:18.330 position:50% align:middle So, Dr. Qian and I, we've been working on this project for the last couple of years, and we're, you know, 00:01:18.330 --> 00:01:22.990 position:50% align:middle here to just kind of share the results with you. 00:01:22.990 --> 00:01:25.030 position:50% align:middle So, this is essentially the agenda. 00:01:25.030 --> 00:01:29.180 position:50% align:middle We'll kind of talk about the background, and you may appreciate the background because it really 00:01:29.180 --> 00:01:34.710 position:50% align:middle will help kind of create a foundation of the overall project as well. 00:01:34.710 --> 00:01:40.500 position:50% align:middle Primarily, we are really interested in clinical judgment and how it affects entry-level nurses or how 00:01:40.500 --> 00:01:43.190 position:50% align:middle they engage in clinical judgment. 00:01:43.190 --> 00:01:47.090 position:50% align:middle But in order to do that, we also wanted to examine some of the thoughts 00:01:47.090 --> 00:01:48.960 position:50% align:middle around experienced nurses. 00:01:48.960 --> 00:01:53.450 position:50% align:middle We'll talk about the methodology, how we put everything together, the results, and, 00:01:53.450 --> 00:01:58.460 position:50% align:middle you know, some of the study limitations as well, because every study has limitations. 00:01:58.460 --> 00:02:01.790 position:50% align:middle And most importantly, we'll talk about some of the implications, 00:02:01.790 --> 00:02:08.700 position:50% align:middle and not in practice, but in regulations, so many of you would possibly be interested in that. 00:02:08.700 --> 00:02:15.150 position:50% align:middle So, when we think about the background of clinical judgment, my thoughts around this is, 00:02:15.150 --> 00:02:20.040 position:50% align:middle there are so many different variables that affect clinical judgment or how entry-level 00:02:20.040 --> 00:02:21.840 position:50% align:middle nurses make decisions. 00:02:21.840 --> 00:02:25.990 position:50% align:middle But most importantly, some of those three pillars are the client 00:02:25.990 --> 00:02:27.280 position:50% align:middle or the patient. 00:02:27.280 --> 00:02:31.700 position:50% align:middle It's the entry-level nurses themselves, but it's also the practice environment. 00:02:31.700 --> 00:02:36.960 position:50% align:middle Now, one would say it's also education, however, that's a different story of another day, so, 00:02:36.960 --> 00:02:39.230 position:50% align:middle I'll focus on these three. 00:02:39.230 --> 00:02:44.260 position:50% align:middle When you consider the patient or the client, and for NCLEX, we use clients. 00:02:44.260 --> 00:02:44.840 position:50% align:middle So, I'm a nurse. 00:02:44.840 --> 00:02:49.160 position:50% align:middle I use those terms interchangeably all day. 00:02:49.160 --> 00:02:53.460 position:50% align:middle Years ago, our clients were so much different than they are now. 00:02:53.460 --> 00:02:55.750 position:50% align:middle Length of stays were longer. 00:02:55.750 --> 00:03:00.980 position:50% align:middle If you can imagine a time when you would care for a client that was coming in and had a normal 00:03:00.980 --> 00:03:06.880 position:50% align:middle vaginal delivery, the client was probably an inpatient for several days, sometimes up to a week. 00:03:06.880 --> 00:03:09.230 position:50% align:middle That absolutely does not occur now. 00:03:09.230 --> 00:03:14.210 position:50% align:middle We used to take care of total hip replacements that went to surgery for ORIF. 00:03:14.210 --> 00:03:18.820 position:50% align:middle Those clients were absolutely in our care for at least a week. 00:03:18.820 --> 00:03:23.400 position:50% align:middle There was some kind of...I mean, even when we think about currently right now, 00:03:23.400 --> 00:03:28.890 position:50% align:middle clients are older, there's a lot of data that supports that our client population is aging. 00:03:28.890 --> 00:03:29.970 position:50% align:middle They're living longer. 00:03:29.970 --> 00:03:37.460 position:50% align:middle But the interesting thing about that is they're living longer, but they now have more chronic illnesses. 00:03:37.460 --> 00:03:43.600 position:50% align:middle So, historically, they had acute illnesses, but now they have more chronic unstable conditions. 00:03:43.600 --> 00:03:46.140 position:50% align:middle So, that's really something to contend with. 00:03:46.140 --> 00:03:48.470 position:50% align:middle So, our patient population is very different. 00:03:48.470 --> 00:03:55.360 position:50% align:middle When we think about the practice environment, I like to make the statement that licensure doesn't 00:03:55.360 --> 00:03:57.140 position:50% align:middle dictate practice settings. 00:03:57.140 --> 00:04:04.230 position:50% align:middle And what that means is when a nurse gets their license, they can work in any setting. 00:04:04.230 --> 00:04:10.100 position:50% align:middle But when you consider possibly 20 years ago, for some reason, there was a professional agreement. 00:04:10.100 --> 00:04:14.800 position:50% align:middle There was no rule, but there was an, a professional agreement that entry-level nurses 00:04:14.800 --> 00:04:17.810 position:50% align:middle entered into relatively benign settings. 00:04:17.810 --> 00:04:22.390 position:50% align:middle They worked in med-surg settings, and they did this phenomenon, you know, 00:04:22.390 --> 00:04:26.140 position:50% align:middle you got your experience, and then you certainly kind of went 00:04:26.140 --> 00:04:28.330 position:50% align:middle on to another place. 00:04:28.330 --> 00:04:34.660 position:50% align:middle If anyone is familiar with the Patricia Benner's model around skill attainment, novice to expert, 00:04:34.660 --> 00:04:38.420 position:50% align:middle you'll begin to appreciate what some of that means. 00:04:38.420 --> 00:04:43.470 position:50% align:middle And when we consider that an entry-level nurse, once they pass the NCLEX, 00:04:43.470 --> 00:04:48.210 position:50% align:middle I like to say that that's their ticket to the dance. 00:04:48.210 --> 00:04:50.370 position:50% align:middle It gets them in the door. 00:04:50.370 --> 00:04:56.490 position:50% align:middle However, they still need a lot more support in order to move along that Patricia Benner's model in terms 00:04:56.490 --> 00:05:01.110 position:50% align:middle of skill attainment, which primarily is achieved through practice, you know, 00:05:01.110 --> 00:05:02.940 position:50% align:middle those clinical hours. 00:05:02.940 --> 00:05:06.890 position:50% align:middle So, we do, you know, kind of have a different environment in which entry 00:05:06.890 --> 00:05:08.780 position:50% align:middle level nurses are practicing. 00:05:08.780 --> 00:05:11.190 position:50% align:middle They need a lot more support. 00:05:11.190 --> 00:05:15.720 position:50% align:middle Of course, we have the perpetual nursing shortage. 00:05:15.720 --> 00:05:22.200 position:50% align:middle Now we're also faced with another phenomenon where we have more of our baby boomer nurses that 00:05:22.200 --> 00:05:24.090 position:50% align:middle are now retiring. 00:05:24.090 --> 00:05:26.620 position:50% align:middle And so, who will replace them? 00:05:26.620 --> 00:05:28.130 position:50% align:middle Entry-level nurses. 00:05:28.130 --> 00:05:35.600 position:50% align:middle But now we are entering into a dynamic where we'll have a disproportionate skill mix where traditionally, 00:05:35.600 --> 00:05:41.390 position:50% align:middle entry-level nurses are reliant on experienced nurses to say, "Hey, you know, what do you think about this? 00:05:41.390 --> 00:05:42.310 position:50% align:middle Take a look at that. 00:05:42.310 --> 00:05:43.830 position:50% align:middle Can you help me with this?" 00:05:43.830 --> 00:05:48.430 position:50% align:middle That doesn't happen forever, but it does usually occur more often in that transition 00:05:48.430 --> 00:05:54.690 position:50% align:middle to practice period, in that early entry-level period as they're beginning to gain their clinical hours 00:05:54.690 --> 00:05:57.340 position:50% align:middle along that skill-attainment road. 00:05:57.340 --> 00:06:01.640 position:50% align:middle So, just so many different dynamics that come into play. 00:06:01.640 --> 00:06:07.250 position:50% align:middle When we think about our entry-level nurses, and you guys can probably attest to this, 00:06:07.250 --> 00:06:12.630 position:50% align:middle the generation of entry-level nurses that enter into workforce are just very different, not right or wrong, 00:06:12.630 --> 00:06:14.150 position:50% align:middle just very different. 00:06:14.150 --> 00:06:20.860 position:50% align:middle So, we really do have to figure out how to create a scaffolding in order to help support and facilitate 00:06:20.860 --> 00:06:23.100 position:50% align:middle safe and effective care. 00:06:23.100 --> 00:06:28.330 position:50% align:middle And one of the ways that we are looking at creating that scaffolding is in clinical judgment, 00:06:28.330 --> 00:06:29.560 position:50% align:middle how they make decisions. 00:06:29.560 --> 00:06:37.670 position:50% align:middle Because primarily, the problem is, entry-level nurses, they make ineffective clinical judgment, not right, 00:06:37.670 --> 00:06:42.150 position:50% align:middle not wrong, that's just what it is, because they're really in that place where they haven't 00:06:42.150 --> 00:06:47.310 position:50% align:middle gotten a chance where they have enough of those hours under their scaffolding. 00:06:47.310 --> 00:06:53.260 position:50% align:middle So, some data that you see here, all of those variables that I just mentioned kind 00:06:53.260 --> 00:07:01.220 position:50% align:middle of result here that novice nurses are more likely to commit a practice error, and that's just inevitable. 00:07:01.220 --> 00:07:06.080 position:50% align:middle It's certainly not an environment where you want to be punitive, but you wanna create an environment 00:07:06.080 --> 00:07:09.460 position:50% align:middle to help them, you know, kind of decrease that practice error. 00:07:09.460 --> 00:07:13.820 position:50% align:middle And a part of it is really helping them to make clinical decisions. 00:07:13.820 --> 00:07:20.050 position:50% align:middle We know that many employers are dissatisfied with how entry-level nurses are showing up in terms of work. 00:07:20.050 --> 00:07:25.680 position:50% align:middle And what that really means is, there's just a disconnect between the expectations and 00:07:25.680 --> 00:07:27.640 position:50% align:middle who shows up on the first day. 00:07:27.640 --> 00:07:33.320 position:50% align:middle I think traditionally as a profession, there are some schools of thought that as soon as you 00:07:33.320 --> 00:07:36.940 position:50% align:middle get your license, your NCLEX, okay, yeah, let's go, you're ready. 00:07:36.940 --> 00:07:39.620 position:50% align:middle Well, that's absolutely not congruent. 00:07:39.620 --> 00:07:47.390 position:50% align:middle When we think about in a medical model, a physician has a required residency, 00:07:47.390 --> 00:07:54.350 position:50% align:middle and part of that period is to support that new physician as they're gaining those additional skill 00:07:54.350 --> 00:07:55.900 position:50% align:middle and practice hours. 00:07:55.900 --> 00:08:01.930 position:50% align:middle In our profession, that's not required, nor is it always embedded in practice. 00:08:01.930 --> 00:08:08.250 position:50% align:middle So, we do have a dynamic where we have new nurses that need the support, but we're struggling to try to figure 00:08:08.250 --> 00:08:12.280 position:50% align:middle out how to create that environment. 00:08:12.280 --> 00:08:17.010 position:50% align:middle So, I think ultimately, you know, just kind of that last point was that clinical decision 00:08:17.010 --> 00:08:20.060 position:50% align:middle making is very important in the entry level period. 00:08:20.060 --> 00:08:24.960 position:50% align:middle Because once again, when you think about, you know, sometimes there are thoughts that, "Oh, well, 00:08:24.960 --> 00:08:28.690 position:50% align:middle this is a new nurse, and we don't give new nurses those kind of patients." 00:08:28.690 --> 00:08:33.090 position:50% align:middle Well, you may not in hospital A, but in hospital B, they do. 00:08:33.090 --> 00:08:37.610 position:50% align:middle So, there's always this thought around whoever the entry-level nurse is, 00:08:37.610 --> 00:08:41.370 position:50% align:middle we do have to create that environment to help them practice safely. 00:08:41.370 --> 00:08:46.690 position:50% align:middle So, the council, as we were developing our work around clinical judgment and the assessment of it, 00:08:46.690 --> 00:08:49.270 position:50% align:middle we purposefully created a definition of it. 00:08:49.270 --> 00:08:51.030 position:50% align:middle And I really like this definition. 00:08:51.030 --> 00:08:52.260 position:50% align:middle It's in our practice analysis. 00:08:52.260 --> 00:08:53.840 position:50% align:middle It's in a test plan. 00:08:53.840 --> 00:08:59.360 position:50% align:middle And primarily, what it does is creates just essentially a baseline of what it is. 00:08:59.360 --> 00:09:04.870 position:50% align:middle We know we've heard of critical thinking and decision making, but clinical judgment is 00:09:04.870 --> 00:09:06.510 position:50% align:middle that iterative process. 00:09:06.510 --> 00:09:10.980 position:50% align:middle It is the result of the thinking that you do and you actually make a decision. 00:09:10.980 --> 00:09:15.080 position:50% align:middle So, the important piece here is, we know that entry-level nurses, 00:09:15.080 --> 00:09:18.780 position:50% align:middle they have a lot of that base knowledge, but what's important is, 00:09:18.780 --> 00:09:24.050 position:50% align:middle as you're processing that base knowledge, how do you then move forward to make the effective 00:09:24.050 --> 00:09:27.420 position:50% align:middle decision to be sure that you're doing the right thing. 00:09:27.420 --> 00:09:32.930 position:50% align:middle The other piece that it does in terms of the iterativeness, it ensures that the entry-level nurse, 00:09:32.930 --> 00:09:38.100 position:50% align:middle once they get to a place where they make a decision, they have to evaluate the effectiveness 00:09:38.100 --> 00:09:39.310 position:50% align:middle of their decision. 00:09:39.310 --> 00:09:44.550 position:50% align:middle Not that they implemented a intervention, "Okay, I'm done," but did it work? 00:09:44.550 --> 00:09:45.910 position:50% align:middle Did it because harm? 00:09:45.910 --> 00:09:47.910 position:50% align:middle Do you have to do something else? 00:09:47.910 --> 00:09:51.840 position:50% align:middle And if it's effective, now you just return through the cycle and address the 00:09:51.840 --> 00:09:53.510 position:50% align:middle next priority problem. 00:09:53.510 --> 00:09:59.280 position:50% align:middle So, we wanted to create that framework so that we're all working from the same plane. 00:09:59.280 --> 00:10:06.790 position:50% align:middle So, Dr. Qian and I, we looked at a lot of our practice analysis data, and we were able to essentially describe 00:10:06.790 --> 00:10:08.330 position:50% align:middle today's entry-level nurse. 00:10:08.330 --> 00:10:12.450 position:50% align:middle And the rest of the presentation, the information will be presented in both ways. 00:10:12.450 --> 00:10:18.750 position:50% align:middle We know that we're interested in entry-level nursing, not only at RN, but as PN as well. 00:10:18.750 --> 00:10:24.870 position:50% align:middle So, according to the practice analysis data analyzed over several years, this is kind of a snapshot of who a 00:10:24.870 --> 00:10:27.140 position:50% align:middle new nurse is as an RN. 00:10:27.140 --> 00:10:32.010 position:50% align:middle One of the things that we'll highlight here is at the end is that there is an increase in formal 00:10:32.010 --> 00:10:36.110 position:50% align:middle orientation internships, which is actually very promising in terms 00:10:36.110 --> 00:10:38.030 position:50% align:middle of creating that support. 00:10:38.030 --> 00:10:48.740 position:50% align:middle The other thing that we do see is that entry-level RNs, they are beginning to increase a presence in more 00:10:48.740 --> 00:10:52.640 position:50% align:middle critical care areas, emergency departments, etc. 00:10:52.640 --> 00:10:57.600 position:50% align:middle Now, what that means is, once again, the care for a client in an ED and an ICU is very 00:10:57.600 --> 00:11:00.540 position:50% align:middle different from the care of a client on a med-surg floor. 00:11:00.540 --> 00:11:05.120 position:50% align:middle Now, granted, med-surg clients, now, they certainly have a very high acuity, 00:11:05.120 --> 00:11:06.890 position:50% align:middle and that's important as well. 00:11:06.890 --> 00:11:12.230 position:50% align:middle But when you think about an entry-level nurse that's working in an ED or an ICU, 00:11:12.230 --> 00:11:14.340 position:50% align:middle those are really high-stake clients. 00:11:14.340 --> 00:11:17.980 position:50% align:middle And so, once again, there's no way to prohibit them from working in those areas. 00:11:17.980 --> 00:11:21.890 position:50% align:middle Yes, we should encourage it, but then we also have to figure out how do we make them 00:11:21.890 --> 00:11:26.680 position:50% align:middle safe in those high-risk areas. 00:11:26.680 --> 00:11:29.490 position:50% align:middle And this is kind of the snapshot of the PN. 00:11:29.490 --> 00:11:33.500 position:50% align:middle Now, the interesting two points on here, as you can see, a lot of the characteristics are 00:11:33.500 --> 00:11:39.850 position:50% align:middle the same, but the two things that really jump out for me for the PN population is, A, 00:11:39.850 --> 00:11:45.160 position:50% align:middle they're now beginning to...we probably didn't capture it here, but PNs are now beginning to work more 00:11:45.160 --> 00:11:47.290 position:50% align:middle regularly in acute care settings. 00:11:47.290 --> 00:11:52.960 position:50% align:middle I know you guys probably have seen years ago when there was kind of a mass exodus of PNs in acute care, 00:11:52.960 --> 00:11:55.320 position:50% align:middle they went to long-term care facilities. 00:11:55.320 --> 00:11:59.350 position:50% align:middle On average, they're still there, that that's the largest center. 00:11:59.350 --> 00:12:04.630 position:50% align:middle But we do see that there is an increased trend that they're moving into acute care settings. 00:12:04.630 --> 00:12:10.610 position:50% align:middle So, the care that a PN nurse would traditionally give kind of our framework around that, 00:12:10.610 --> 00:12:14.940 position:50% align:middle we really do have to rethink that because if we're considering that, oh, well, 00:12:14.940 --> 00:12:21.730 position:50% align:middle a PN nurse would be responsible for, you know, 15, 20 patients on a ward, she's passing medications, 00:12:21.730 --> 00:12:24.210 position:50% align:middle you know, he or she, they're doing wound care. 00:12:24.210 --> 00:12:29.240 position:50% align:middle Well, now you take that same person who does have a license to work in an ICU. 00:12:29.240 --> 00:12:29.940 position:50% align:middle Now, what do you do? 00:12:29.940 --> 00:12:34.710 position:50% align:middle You have to really think about how do you make that person safe in that area as well. 00:12:34.710 --> 00:12:42.570 position:50% align:middle But the other thing about PNs, unlike RNs, PNs are more likely to than RNs not have any 00:12:42.570 --> 00:12:44.220 position:50% align:middle orientation at all. 00:12:44.220 --> 00:12:47.070 position:50% align:middle And that's very interesting. 00:12:47.070 --> 00:12:53.980 position:50% align:middle So, this graph is just a depiction of, we looked at entry-level RN orientation over the years. 00:12:53.980 --> 00:12:57.700 position:50% align:middle And as you can see, the orange line is the model of the preceptor model. 00:12:57.700 --> 00:13:01.270 position:50% align:middle So, overall, that is pretty much the predominant model. 00:13:01.270 --> 00:13:08.390 position:50% align:middle But the one thing that you probably see around 2017 is that model...well, actually, before then, around 2011, 00:13:08.390 --> 00:13:16.490 position:50% align:middle that model started to dip and there's an increase in the propensity of entry-level nurses engaging in nurse 00:13:16.490 --> 00:13:22.270 position:50% align:middle residency programs, which is extremely promising because you want that kind of orientation and 00:13:22.270 --> 00:13:28.660 position:50% align:middle onboarding to give them that support and scaffolding as they're continuing to work. 00:13:28.660 --> 00:13:33.590 position:50% align:middle And the grade line is just kind of on average that those nurse residency programs were 00:13:33.590 --> 00:13:38.620 position:50% align:middle about 13 weeks overall. 00:13:38.620 --> 00:13:43.310 position:50% align:middle A different snapshot of the PN orientation is, as you can see, I've kind of, you know, 00:13:43.310 --> 00:13:48.960 position:50% align:middle called out a few numbers, and we're starting to see PNs, that number increasing, 00:13:48.960 --> 00:13:52.520 position:50% align:middle them receiving no orientation. 00:13:52.520 --> 00:13:54.440 position:50% align:middle That's a bit frightening. 00:13:54.440 --> 00:14:00.430 position:50% align:middle When you think that a PN shows up to work, this is here's or her first day, and they're given, 00:14:00.430 --> 00:14:03.350 position:50% align:middle "Okay, this is the bathroom, the med cart. 00:14:03.350 --> 00:14:05.480 position:50% align:middle These are your 10 patients. 00:14:05.480 --> 00:14:06.910 position:50% align:middle Have at it." 00:14:06.910 --> 00:14:11.530 position:50% align:middle Imagine the 10 patients behind the care of that PN person. 00:14:11.530 --> 00:14:14.760 position:50% align:middle So, we really do have to figure out how to, you know, merge that. 00:14:14.760 --> 00:14:20.010 position:50% align:middle The other one is, once again, kind of a dip, work with assigned preceptors with or 00:14:20.010 --> 00:14:21.310 position:50% align:middle without additional classroom help. 00:14:21.310 --> 00:14:28.170 position:50% align:middle So, even those that do receive that kind of orientation, that number is becoming less. 00:14:28.170 --> 00:14:32.410 position:50% align:middle So, for our PN nurses, we really want to figure out how to embed that, 00:14:32.410 --> 00:14:37.350 position:50% align:middle because traditionally...even we did ask them about nurse residency programs, 00:14:37.350 --> 00:14:40.380 position:50% align:middle some of them stated that they engaged in it, but it was only about, 00:14:40.380 --> 00:14:42.380 position:50% align:middle I think on average about four weeks. 00:14:42.380 --> 00:14:48.060 position:50% align:middle So, we know that traditionally, nurse residency programs last a lot longer than that. 00:14:48.060 --> 00:14:54.690 position:50% align:middle So, it was probably a well-developed onboarding, you know, maybe perhaps a different kind of approach 00:14:54.690 --> 00:14:56.760 position:50% align:middle to nurse residencies. 00:14:56.760 --> 00:15:07.340 position:50% align:middle So, the takeaway here is RPNs may be really a reflection of not receiving a consistent orientation. 00:15:07.340 --> 00:15:14.170 position:50% align:middle So, the methodology that we used in gathering the information in this project, we mixed method study. 00:15:14.170 --> 00:15:18.040 position:50% align:middle We wanted to kind of attack it, you know, from several ends. 00:15:18.040 --> 00:15:23.560 position:50% align:middle What we did was we used essentially a convenient sample of nurse volunteers that come to help us 00:15:23.560 --> 00:15:25.020 position:50% align:middle develop the NCLEX. 00:15:25.020 --> 00:15:29.520 position:50% align:middle So, they really do allow us to ask them a lot of different questions and were able to get a lot 00:15:29.520 --> 00:15:37.240 position:50% align:middle of different information and convenience sample of 73 nurses, and we had about 8 different sessions. 00:15:37.240 --> 00:15:41.520 position:50% align:middle And some of these sessions were RN focused and some of the sessions were PN-focused. 00:15:41.520 --> 00:15:48.620 position:50% align:middle But we also engaged them in an educational setting because we really did want to know more about what 00:15:48.620 --> 00:15:53.160 position:50% align:middle they're experiencing with their entry-level nurses and perhaps what are some of those variables that affect 00:15:53.160 --> 00:15:56.400 position:50% align:middle how entry-level nurses make decisions. 00:15:56.400 --> 00:15:58.720 position:50% align:middle And the quantitative piece was, I hope that's... 00:15:58.720 --> 00:15:59.020 position:50% align:middle Okay. 00:15:59.020 --> 00:16:04.770 position:50% align:middle The quantitative piece was we did two surveys after the actual qualitative sessions, 00:16:04.770 --> 00:16:07.180 position:50% align:middle and I'll talk a little bit more about that. 00:16:07.180 --> 00:16:11.410 position:50% align:middle So, once again, more of the respondent characteristics. 00:16:11.410 --> 00:16:16.440 position:50% align:middle You see that there is male, female, once again, that's kind of representative of nursing 00:16:16.440 --> 00:16:22.930 position:50% align:middle population overall, as you can see, comparative sample in terms of RN and PN sessions. 00:16:22.930 --> 00:16:27.580 position:50% align:middle And we also asked them in terms of what their experience is. 00:16:27.580 --> 00:16:33.750 position:50% align:middle And as you can see, primarily the dominant representation in the sample population was at least 10 00:16:33.750 --> 00:16:35.900 position:50% align:middle to 19 or 20 years or more. 00:16:35.900 --> 00:16:38.630 position:50% align:middle So, nurses with quite a bit of experience. 00:16:38.630 --> 00:16:46.820 position:50% align:middle The one main criteria that's essential is all of the participants interact or supervise or work 00:16:46.820 --> 00:16:50.270 position:50% align:middle alongside with or educate entry-level nurses. 00:16:50.270 --> 00:16:55.570 position:50% align:middle So, it's not just a nurse that perhaps knows another nurse on another unit that really do work 00:16:55.570 --> 00:16:56.730 position:50% align:middle with them directly. 00:16:56.730 --> 00:17:03.090 position:50% align:middle And it has a lot of information behind how an entry-level nurse performs. 00:17:03.090 --> 00:17:08.120 position:50% align:middle So, digging a bit deeper, we looked at the characteristics in terms of locations. 00:17:08.120 --> 00:17:12.910 position:50% align:middle So, it's important for us to figure out that we were representing a cross-section. 00:17:12.910 --> 00:17:16.120 position:50% align:middle So, as you can see, NCSBN, we divide the U.S. 00:17:16.120 --> 00:17:21.940 position:50% align:middle within four areas, and we had an ample representation in all of four areas, 00:17:21.940 --> 00:17:26.100 position:50% align:middle but we also invite Canadian nurses to our panels as well. 00:17:26.100 --> 00:17:31.070 position:50% align:middle So, we did have Canadian representation and we divide their areas into three, 00:17:31.070 --> 00:17:33.120 position:50% align:middle and those are the ones you see here. 00:17:33.120 --> 00:17:38.520 position:50% align:middle So, we felt like we had a really good representation across the nation and even from our Canadian 00:17:38.520 --> 00:17:43.160 position:50% align:middle counterparts as we were engaging them in this process. 00:17:43.160 --> 00:17:48.530 position:50% align:middle So, the qualitative piece consisted of, we used a consistent PowerPoint presentation, 00:17:48.530 --> 00:17:54.250 position:50% align:middle it was 30 minutes, and we took them through those, essentially the 3 topics that you see here. 00:17:54.250 --> 00:17:57.600 position:50% align:middle We talked about clinical judgment, very similar to the background that I just 00:17:57.600 --> 00:17:59.000 position:50% align:middle gave you here. 00:17:59.000 --> 00:18:04.190 position:50% align:middle We talked about some of the entry-level nurse characteristics, those things that entry-level nurses 00:18:04.190 --> 00:18:09.210 position:50% align:middle struggle with, role, ambiguity, they struggle with skill attainment, 00:18:09.210 --> 00:18:11.260 position:50% align:middle they need a lot of support. 00:18:11.260 --> 00:18:14.900 position:50% align:middle They're really stressed in that entry-level period. 00:18:14.900 --> 00:18:18.170 position:50% align:middle We talked about the practice environment, very similar to those things that I 00:18:18.170 --> 00:18:20.040 position:50% align:middle talked about earlier. 00:18:20.040 --> 00:18:24.630 position:50% align:middle And interestingly, the three things that you see here...they gave us a lot of information, 00:18:24.630 --> 00:18:29.690 position:50% align:middle but these were some of the three recurring things, anecdotal, because we didn't ask for numbers, 00:18:29.690 --> 00:18:35.440 position:50% align:middle but what I thought was very interesting is they we're very focused on the fact that entry-level nurses are 00:18:35.440 --> 00:18:43.240 position:50% align:middle beginning to not work full time, that many of them work PRN, they work as travel nurses. 00:18:43.240 --> 00:18:49.850 position:50% align:middle So, they felt that that was a piece that may essentially impact how they make clinical judgment. 00:18:49.850 --> 00:18:54.650 position:50% align:middle Of course, we talked about them in terms of working in those specialty areas, but they also mentioned, 00:18:54.650 --> 00:18:59.760 position:50% align:middle once again, this is anecdotal, no data on it, that they felt like their experience that more 00:18:59.760 --> 00:19:03.610 position:50% align:middle entry-level nurses were turning over in that entry-level period. 00:19:03.610 --> 00:19:09.360 position:50% align:middle So, whether it was within going from one unit to the next or just even one institution to the next, 00:19:09.360 --> 00:19:13.770 position:50% align:middle that entry-level nurses were turning moreover, more frequently in that entry-level period. 00:19:13.770 --> 00:19:20.050 position:50% align:middle So, once again, thinking that that somehow had some impact in the overall. 00:19:20.050 --> 00:19:25.190 position:50% align:middle So, the piece that we then went to was the survey piece. 00:19:25.190 --> 00:19:29.810 position:50% align:middle And all of the 73 individuals, they completed Survey One. 00:19:29.810 --> 00:19:33.340 position:50% align:middle And if you can recall, I know many of you are already familiar with the NCLEX 00:19:33.340 --> 00:19:37.130 position:50% align:middle test plan, but how we developed the NCLEX test plan is through the practice analysis. 00:19:37.130 --> 00:19:43.980 position:50% align:middle And the practice analysis is a list of entry-level activities that nurses engage in as they're 00:19:43.980 --> 00:19:45.300 position:50% align:middle caring for patients. 00:19:45.300 --> 00:19:49.680 position:50% align:middle For RN, I want to say it is 147 and Hong is probably going to correct me. 00:19:49.680 --> 00:19:53.730 position:50% align:middle And for PN it's 151, or maybe the converse. 00:19:53.730 --> 00:19:54.580 position:50% align:middle Anyway. 00:19:54.580 --> 00:20:00.070 position:50% align:middle What we do is we send those surveys out and we're asking the entry-level nurses to give us information 00:20:00.070 --> 00:20:04.680 position:50% align:middle regarding if they actually engage in that activity. 00:20:04.680 --> 00:20:06.280 position:50% align:middle If so, how often? 00:20:06.280 --> 00:20:07.880 position:50% align:middle And in what setting? 00:20:07.880 --> 00:20:13.880 position:50% align:middle How important is that activity as it relates to client safety and prevented complications? 00:20:13.880 --> 00:20:17.840 position:50% align:middle And then lastly, we ask them questions about clinical judgment relevancy. 00:20:17.840 --> 00:20:23.590 position:50% align:middle So, this is the question that we really wanted to focus on, and then take that same kind of survey dynamic and 00:20:23.590 --> 00:20:25.800 position:50% align:middle give it to the experienced nurses. 00:20:25.800 --> 00:20:33.370 position:50% align:middle So, we were asking them, of those 147 and 151 activity statements are in NPN, 00:20:33.370 --> 00:20:39.860 position:50% align:middle how relevant is clinical judgment in the delivery of those statements by an entry-level nurse, 00:20:39.860 --> 00:20:42.680 position:50% align:middle not themselves, but by an entry-level nurse? 00:20:42.680 --> 00:20:46.720 position:50% align:middle So, as you can see, the Likert scale that you see here, one is not relevant, 00:20:46.720 --> 00:20:51.280 position:50% align:middle all the way through to four being essential. 00:20:51.280 --> 00:20:55.970 position:50% align:middle And that's just kind of a snapshot of what the survey question looked like. 00:20:55.970 --> 00:20:58.920 position:50% align:middle So, this is the first snapshot of the data. 00:20:58.920 --> 00:21:04.910 position:50% align:middle Now, I think one of the things that you can probably appreciate is a lot of the data points kind 00:21:04.910 --> 00:21:09.220 position:50% align:middle of aggregate at least above the three. 00:21:09.220 --> 00:21:13.720 position:50% align:middle And if we kind of look back at the Likert scale...oh, nope, it's there at the bottom. 00:21:13.720 --> 00:21:15.270 position:50% align:middle Okay. 00:21:15.270 --> 00:21:17.020 position:50% align:middle At least important. 00:21:17.020 --> 00:21:22.528 position:50% align:middle So, on average, the average rating was 3.37. 00:21:22.528 --> 00:21:30.620 position:50% align:middle So, the experienced nurses felt that those number of activity statements on average were important 00:21:30.620 --> 00:21:37.930 position:50% align:middle between important moving on into essential as an entry-level nurse is engaging in that care. 00:21:37.930 --> 00:21:42.230 position:50% align:middle And so, one of the things that we wanted to do is even in the practice analysis, 00:21:42.230 --> 00:21:46.890 position:50% align:middle we use that as a cross-section because we're asking entry-level nurses the questions, 00:21:46.890 --> 00:21:52.120 position:50% align:middle but we're also asking experienced nurses, because sometimes we realize that, you know, 00:21:52.120 --> 00:21:55.910 position:50% align:middle there's some school of thought that a new nurse may not know what she doesn't know. 00:21:55.910 --> 00:22:03.150 position:50% align:middle So, we wanted to be sure to ask experienced nurses what is their thoughts and their experience as the relevancy 00:22:03.150 --> 00:22:04.220 position:50% align:middle of clinical judgment. 00:22:04.220 --> 00:22:06.120 position:50% align:middle Standard deviation was relatively low. 00:22:06.120 --> 00:22:12.860 position:50% align:middle So, a lot of consistency in the ratings. 00:22:12.860 --> 00:22:19.250 position:50% align:middle The other thing that comes out on this survey, there was one portion of the survey that we allowed a 00:22:19.250 --> 00:22:22.330 position:50% align:middle question that they could respond to that they just didn't know. 00:22:22.330 --> 00:22:29.560 position:50% align:middle So, let's say one of the surveys had 147 activity statements, but along that Likert scale, 00:22:29.560 --> 00:22:32.180 position:50% align:middle one of the responses was that you just don't know. 00:22:32.180 --> 00:22:37.780 position:50% align:middle The one thing that we did find is that of the 73 or however many entry-level nurses that we had, 00:22:37.780 --> 00:22:46.890 position:50% align:middle and times that in terms of those activity statements, there were only approximately 1% of ratings 00:22:46.890 --> 00:22:47.850 position:50% align:middle of don't know. 00:22:47.850 --> 00:22:54.470 position:50% align:middle So, which means that the experienced nurses felt pretty strongly about their ratings, 00:22:54.470 --> 00:22:57.640 position:50% align:middle because they certainly had the opportunity to say, "Well, yeah, I just don't know." 00:22:57.640 --> 00:22:59.020 position:50% align:middle But they did not. 00:22:59.020 --> 00:23:03.800 position:50% align:middle And we just wanted to point this out just as a highlight. 00:23:03.800 --> 00:23:09.740 position:50% align:middle Looking at the PN results, once again, very comparable to the RNs, average rating of 3.42. 00:23:09.740 --> 00:23:15.440 position:50% align:middle So, certainly between important and essential, relatively low standard deviation. 00:23:15.440 --> 00:23:18.350 position:50% align:middle A lot of consistency in the ratings. 00:23:18.350 --> 00:23:23.410 position:50% align:middle So, once again, felt like they felt very strongly about that. 00:23:23.410 --> 00:23:29.010 position:50% align:middle And comparably to RNs, once again, a relatively low 1% rating of those statements that 00:23:29.010 --> 00:23:31.590 position:50% align:middle were associated with them just not knowing. 00:23:31.590 --> 00:23:37.330 position:50% align:middle So, they felt pretty comfortable in the ratings that they provided. 00:23:37.330 --> 00:23:41.180 position:50% align:middle So, the second survey really focused on our measurement model. 00:23:41.180 --> 00:23:43.440 position:50% align:middle So, not just the definition but our measurement model. 00:23:43.440 --> 00:23:47.600 position:50% align:middle And our measurement model is NCSBN Clinical Judgment Measurement Model. 00:23:47.600 --> 00:23:50.460 position:50% align:middle Oh, my good, I can't see that, Jen. 00:23:50.460 --> 00:23:53.140 position:50% align:middle Oh, oh, okay. 00:23:53.140 --> 00:23:56.640 position:50% align:middle That's a hurry-up sign. 00:23:56.640 --> 00:24:02.730 position:50% align:middle And the thing about the measurement model is if you can see on layer three, we focus on those six steps that 00:24:02.730 --> 00:24:06.890 position:50% align:middle starts with recognized cues all the way through evaluate outcomes. 00:24:06.890 --> 00:24:15.090 position:50% align:middle And our interest here is we wanted to understand what was experienced nurses thoughts about how relevant 00:24:15.090 --> 00:24:20.790 position:50% align:middle those steps are in carrying out those activity statements using that same Likert scale. 00:24:20.790 --> 00:24:23.570 position:50% align:middle So, once again, that's just kind of a snapshot of it. 00:24:23.570 --> 00:24:28.000 position:50% align:middle And here we got relatively similar data. 00:24:28.000 --> 00:24:35.650 position:50% align:middle So, on average, 3.34 lower standard deviation using that same Likert scale for the RN. 00:24:35.650 --> 00:24:42.690 position:50% align:middle Now, this one, I'm just over the moon excited about because what this tells me is if you can look at the 00:24:42.690 --> 00:24:47.580 position:50% align:middle comparative ratings for all of those six steps in the Clinical Judgment Model, 00:24:47.580 --> 00:24:49.990 position:50% align:middle what it says is all of them are important. 00:24:49.990 --> 00:24:53.840 position:50% align:middle So, not just one, not two, not this one is more important than the other, 00:24:53.840 --> 00:24:57.350 position:50% align:middle all of them are essentially relatively important. 00:24:57.350 --> 00:25:01.930 position:50% align:middle So, the same thing from PN, those results, you kind of see how a lot of that is aggregated, 00:25:01.930 --> 00:25:04.310 position:50% align:middle at least over the 3 lower standard deviation. 00:25:04.310 --> 00:25:06.870 position:50% align:middle And PN did the same thing. 00:25:06.870 --> 00:25:12.020 position:50% align:middle Now, the interesting thing about is not all 73 nurses were in the same room at the same time. 00:25:12.020 --> 00:25:17.180 position:50% align:middle As I mentioned, we did this over a two-year period, eight different sessions. 00:25:17.180 --> 00:25:19.460 position:50% align:middle So, many of the nurses did not know each other at all. 00:25:19.460 --> 00:25:25.200 position:50% align:middle So, there was no similarities in that way other than what they really think about clinical judgment in terms 00:25:25.200 --> 00:25:26.970 position:50% align:middle of entry-level nurses. 00:25:26.970 --> 00:25:33.030 position:50% align:middle So, some of the study limitations is that the session discussion format, sometimes that was a bit difficult 00:25:33.030 --> 00:25:37.680 position:50% align:middle to keep that consistent because once we got talking, some nurses really wanted to talk 00:25:37.680 --> 00:25:38.500 position:50% align:middle about some other things. 00:25:38.500 --> 00:25:41.720 position:50% align:middle So, it was hard to kind of keep them on track. 00:25:41.720 --> 00:25:42.920 position:50% align:middle A convenient sample. 00:25:42.920 --> 00:25:46.350 position:50% align:middle You know, certainly, this is not generalizable, but, you know, we just, you know, 00:25:46.350 --> 00:25:48.560 position:50% align:middle kind of chose low-hanging fruit. 00:25:48.560 --> 00:25:49.770 position:50% align:middle Participant motivation. 00:25:49.770 --> 00:25:54.550 position:50% align:middle One of the things that we did know, and, you know, we may kind of look at the data a different way, 00:25:54.550 --> 00:25:55.690 position:50% align:middle the surveys were long. 00:25:55.690 --> 00:26:03.580 position:50% align:middle You talk about 147, 151, especially the second survey, we're asking them to rate that survey 6 00:26:03.580 --> 00:26:05.340 position:50% align:middle times per statement. 00:26:05.340 --> 00:26:06.410 position:50% align:middle That's a lot of entry. 00:26:06.410 --> 00:26:09.960 position:50% align:middle So, we did find that some people were just really exhausted. 00:26:09.960 --> 00:26:14.320 position:50% align:middle So, we felt that was kind of, you know, survey fatigue. 00:26:14.320 --> 00:26:20.150 position:50% align:middle So, lastly, just some implications as we are thinking about in terms of the nursing profession, 00:26:20.150 --> 00:26:23.710 position:50% align:middle clinical judgment certainly remains essential. 00:26:23.710 --> 00:26:29.400 position:50% align:middle Entry-level nurses, once they're licensed certainly have the ability to take care of a client just as a 00:26:29.400 --> 00:26:33.850 position:50% align:middle nurse who is on that experience end of the spectrum. 00:26:33.850 --> 00:26:36.900 position:50% align:middle Of course, they have to demonstrate competency within the clinical setting, 00:26:36.900 --> 00:26:42.140 position:50% align:middle but the most important thing is to think about when a nurse walks into the room, on their badge, 00:26:42.140 --> 00:26:45.860 position:50% align:middle it doesn't say how many years, sometimes they do, but it doesn't say how many years that 00:26:45.860 --> 00:26:46.690 position:50% align:middle they've been working. 00:26:46.690 --> 00:26:48.420 position:50% align:middle It just says RN or PN. 00:26:48.420 --> 00:26:55.510 position:50% align:middle And the client in the bed is really hoping that this person has at least, not just the bare minimum, 00:26:55.510 --> 00:26:58.340 position:50% align:middle but know, if something goes wrong, I can at least ask someone else. 00:26:58.340 --> 00:26:59.820 position:50% align:middle That's at least the bare minimum. 00:26:59.820 --> 00:27:07.150 position:50% align:middle Once again, it's definitely important in terms of onboarding and how those programs are situated because 00:27:07.150 --> 00:27:13.400 position:50% align:middle that piece is important as the nurse is once again moving along that novice to expert continuum. 00:27:13.400 --> 00:27:19.380 position:50% align:middle And it absolutely enhances clinical safety and, you know, certainly prevents client complications. 00:27:19.380 --> 00:27:26.170 position:50% align:middle On regulation side, for us, we continue to analyze or explore the relevancy 00:27:26.170 --> 00:27:29.020 position:50% align:middle of clinical judgment as we do the NCLEX. 00:27:29.020 --> 00:27:34.490 position:50% align:middle Right now we are in the process of developing the 2026 test plan. 00:27:34.490 --> 00:27:37.899 position:50% align:middle So, we are launching the practice analysis in 2024. 00:27:37.899 --> 00:27:42.190 position:50% align:middle So, we're already starting this cycle, so we'll begin to ask them again, 00:27:42.190 --> 00:27:45.590 position:50% align:middle what is the relevancy of clinical judgment in that. 00:27:45.590 --> 00:27:49.090 position:50% align:middle And then lastly, you know, I think Brandon kind of mentioned some of the work that 00:27:49.090 --> 00:27:55.110 position:50% align:middle I've been doing in my doctoral program, you know, once I finished, is that there's a lot of literature 00:27:55.110 --> 00:27:59.670 position:50% align:middle that supports when you're developing simulation based on a clinical judgment model, 00:27:59.670 --> 00:28:03.800 position:50% align:middle it really does facilitate clinical judgment behaviors. 00:28:03.800 --> 00:28:11.560 position:50% align:middle So, thinking about how your programs can develop simulation, not just, okay, what's the appropriate, 00:28:11.560 --> 00:28:17.490 position:50% align:middle you know, placement for the stethoscope, you know, we know that, but how can they make effective clinical 00:28:17.490 --> 00:28:22.810 position:50% align:middle judgments when they care for a client that is a failure-to-rescue kind of dynamic. 00:28:22.810 --> 00:28:29.750 position:50% align:middle That really makes sure that there's purposeful engagement of those clinical judgment behaviors. 00:28:29.750 --> 00:28:33.280 position:50% align:middle I think I'm out of time now.