Abstract
Background
Clinical judgment is one of the most important competencies required for safe care, decision-making, and diagnosis in nursing profession. Therefore, it is necessary to examine clinical judgment in nursing care. Existing a standard questionnaire based on cultural and social conditions can accurately evaluate clinical judgment in nurses.
Objective
The present study aimed to develop and validate clinical judgment capability questionnaire in nurses.
Design
The current research was a sequential exploratory mixed method study.
Setting
The teaching hospitals affiliated to Jahrom University of Medical Sciences in the South of Iran in 2023.
Participants
Twelve clinical nurses were included in the qualitative part and 181 nurses in the quantitative part.
Methods
The study was conducted in two parts: one qualitative and one quantitative. In the qualitative part, the concept of clinical judgment was explored using qualitative content analysis. Then, the initial pool of items was generated to develop a questionnaire. In the quantitative part, psychometric properties of the questionnaire were evaluated including face, content, and structure validity and reliability (internal consistency and stability).
Results
After examining the psychometric properties, 22 items were developed for the final questionnaire. The results of factor analysis led to the extraction of four factors, including noticing, interpreting, responding, and reflecting. The internal consistency of the questionnaire was confirmed with a Cronbach's alpha coefficient of 0.95 and its stability with an intraclass correlation coefficient of 0.84.
Conclusion
The developed 22-item questionnaire is a valid and reliable tool for assessment of clinical judgment capability in nurses.
Keywords: Validation, Questionnaire, Clinical judgment, Nursing care, Nurses
What is already known about the topic.
-
•
Clinical judgment is one of the most important competencies required for safe care, decision-making, and diagnosis in nursing.
-
•
Using scientific knowledge in the clinical field is an essential part of the clinical judgment process.
-
•
There are few questionnaires for assessment of clinical judgment in nurses.
Alt-text: Unlabelled box
What this paper adds.
-
•
We developed and validated a 22-item questionnaire to assess nurses' clinical judgment capability.
-
•
In this study, we explored dimensions of clinical judgment in nurses and confirmed the previous findings in this field.
Alt-text: Unlabelled box
1. Introduction
Nursing is a profession facing decision-making challenges during health care services for clients. Nurses need to make accurate clinical judgments to overcome such challenges and make efficient, accurate, and low-cost decisions for patients (Chen et al., 2021). Clinical judgment is one of the most important competencies required for safe care, decision-making, and diagnosis in the nursing profession (Manetti, 2019). Clinical judgment in nursing is a complex term related to concepts such as clinical decision making, critical thinking, clinical reasoning, intuition, nursing diagnosis, nursing process, and problem solving. Although clinical judgment is not a substitute for these concepts, they are related to each other as antecedents or consequences (Manetti, 2019; Dickison et al., 2019). Benner (2019) believes that these concepts are related to each other; however, their definitions and positions are different from each other in the nursing process and patient care.
Clinical judgment is a prerequisite and necessity for clinical decision-making (Manetti, 2019). Concept analysis of clinical reasoning indicates that it is not equivalent to clinical judgment; rather, it is considered as one of the main factors or precursors for clinical judgment (Huhn et al., 2019). Critical thinking is also one of the criteria of clinical judgment and basis of logical thinking to create judgment (Hawkins et al., 2019). Despite numerous studies in this field and frequent use in clinical care, there is no precise and unified definition of this concept (Betts et al., 2019; Abraham et al., 2020).
Clinical judgment has two important dimensions: a technical dimension, which is related to one's scientific foundation, and a human dimension, which is related to the art of clinical judgment in nursing (Kwan et al., 2020). Using scientific knowledge in the clinical field is an essential part of the clinical judgment process (Klenke-Borgmann et al., 2020). Discipline, human judgment, and patient knowledge are abstract dimensions of clinical judgment in practice, which has led to lack of clarity (Kwan et al., 2020; Cai et al., 2019).
In the literature, researchers have emphasized the existence of an accurate measurement tool to evaluate clinical judgment of nurses (Yang et al., 2019; Connor et al., 2023). There is no specific questionnaire tailored to the cultural and contextual background in Iranian healthcare system. One of the available general tools is the Lasater evidence-based guide, which was designed in 2007 in simulated conditions. This questionnaire includes 11 clinical indicators and four dimensions of noticing, interpreting, responding, and reflecting (Lasater, 2007). These questionnaires are developed according to cultural contexts of other countries, which are different from the Iranian context and cannot accurately measure the clinical judgment capability of Iranian nurses. Also, the Lasater questionnaire was designed based on a review of texts and simulations, and nurses' views and experiences were not used to generate questionnaire items. More importantly, Lasater developed this rubric for educational use in the context of simulation classes for nursing students. Meanwhile, instrument experts believe that a questionnaire designed in another country reflects only the language and culture of the same society where it was developed, and it is not suitable for use in another, even if the items have been accurately translated. The lack of suitability is due to a mismatch of content, context, and culture (Dörnyei and Dewaele, 2022; Kemerli and Celik, 2017). Another questionnaire was constructed by Pouralizadeh et al (2017) to measure the influencing factors of clinical judgment in nursing students. This questionnaire includes 38 items and four factors of thoughtful monitoring, informational and ethical facilitators, educational and environmental facilitators, and collaborative care. It also deals with factors affecting the clinical judgment of nursing students. Therefore, there is a need for a standard, specific, and valid questionnaire that reflects the cultural, social conditions and policies governing the health care and nursing system in Iran.
Objective: this study was conducted with the aim of development and validation of the nurse's clinical judgment capability questionnaire for self-assessment in a mixed method qualitative-quantitative study.
2. Methods
2.1. Study design
This is a sequential exploratory mixed method study, which was conducted in two parts: one qualitative and one quantitative (Othman, Steen & Fleet, 2020). The data were collected from nurses working in the teaching hospitals affiliated with Jahrom University of Medical Sciences (South of Iran). The phases of the study are described in the following sections (Fig. 1).
Fig. 1.
A summary of the instrument development and psychometric evaluation.
2.1.1. Part I: Qualitative study
The qualitative part of the study was conducted using content analysis to explore dimensions of clinical judgment capability in nurses (Dehghani, Makaremnia & Rahmanian, 2023). The participants were 12 clinical nurses recruited through purposive sampling (Table 1). Primary participants were selected from nurses the researcher knew. Further participants were selected by purposive sampling. The inclusion criteria were nurses wanting to participate in the study, the ability to speak Persian, the willingness to provide information through interviews, and at least one year of bedside clinical working experience.
Table 1.
Demographic characteristics of the study participants in the qualitative section.
| Participants | Sex | Age (years) | Work experience (years) | Education | Position |
|---|---|---|---|---|---|
| 1 | Female | 42 | 19 | Bachelor's degree | Head nurse |
| 2 | Female | 44 | 17 | Master's degree | Nurse |
| 3 | Male | 40 | 18 | Bachelor's degree | Nurse |
| 4 | Male | 32 | 10 | Master's degree | Nurse |
| 5 | Female | 27 | 5 | Master's degree | Nurse |
| 6 | Male | 26 | 3 | Bachelor's degree | Nurse |
| 7 | Female | 32 | 6 | Bachelor's degree | Nurse |
| 8 | Female | 34 | 12 | Bachelor's degree | Nurse |
| 9 | Male | 36 | 10 | Master's degree | Nurse |
| 10 | Female | 24 | 2 | Bachelor's degree | Nurse |
| 11 | Female | 39 | 16 | Bachelor's degree | Head nurse |
| 12 | Male | 27 | 5 | Master's degree | Nurse |
This part used semi-structured, in-depth individual interviews to collect data. The interviews were conducted in a calm environment and at a time and place suitable to the participants. We continued to recruit and interview nurses until we reached data saturation. A set of questions was used to guide the interview. The interview started with general questions. With the progress of the interviews and concurrent data analysis, we asked more detailed questions. The following questions guided the interview:
-
1)
Can you tell me what points you pay attention to in taking care of patients?
-
2)
What do you pay attention to when prioritizing patients for care?
-
3)
What is clinical judgment? What dimensions and areas do you think it includes?
-
4)
What experiences (positive and negative) do you have using clinical judgment skills in the nursing care of patients?
-
5)
In your opinion, what are the characteristics of nurses who have clinical judgment skills?
In this study, data analysis was performed using Granheim and Landman's (2004) approach. After conducting each interview, transcripts of the interviews were entered into Microsoft Word immediately. Then, the data were transferred to the MAXQDA software version 20 to organize and code the data. The interviews were read paragraph by paragraph for several times to obtain a general understanding. Then the primary codes were extracted. In the next step, subcategories and categories were generated based on similarity of extracted codes.
Based on the categories in the qualitative part of the study and a literature review, we formed a pool of clinical judgment items in nurses. In the literature review, several valid scientific databases in Persian and English languages were used to retrieve the most relevant information about clinical judgment. The Persian databases of Scientific Information Database, Iranian Magazines, and Iranian Research Institute for Information Science and Technology and the English databases of Web of Science, PubMed, Scopus, Science direct, and Google Scholar were assessed.
2.1.2. Part II: Quantitative study
In this phase, the validity (face, content and structure) and reliability (internal consistency and stability) of the developed questionnaire were examined.
2.1.2.1. Face validity
Face validity was investigated using two methods of qualitative and quantitative. To examine qualitative face validity, 10 nurses, similar to the target group, were recruited through convenience sampling. Nurses were interviewed to assess each item for ambiguity, difficulty, and appropriateness. In order to determine quantitative face validity, the questionnaire was completed by 15 nurses, and the item impact score was calculated. A 5-option Likert scale was considered for each item: completely important, important, almost important, slightly important, and not important. Then the impact score of each item was calculated based on the following formula (Sarkhani et al., 2023):
| Impact Score = Frequency × Importance |
2.1.2.2. Content validity
Two methods of qualitative and quantitative were used to examine content validity. To examine qualitative content validity, opinions of 10 experts with necessary knowledge and experience in questionnaire development and experts in nursing were used regarding the criteria of grammar compliance, use of appropriate words, placement of items in the proper place, and appropriate scoring of items. To check quantitative content validity, two indices of content validity ratio (CVR) and content validity index (CVI) were examined based on the opinions of 10 experts. Necessity of the items was assessed on a 3-part scale (necessary, useful but not necessary, not necessary) (Polit and Beck, 2020; Binti Hassan, 2018). The CVI was examined in order to check relevance of the items on a 4-point scale: not relevant, somewhat relevant, quite relevant, and very relevant (Woo, 2017). The result obtained from the CVR was evaluated according to the number of experts with the criteria in the table of Lawshe (Polit and Beck, 2020). According to Polit and Beck, a CVI equal to 0.79 is excellent, regardless of the number of experts.
2.1.2.3. Initial reliability
Before factor analysis, the Cronbach's alpha coefficient of the questionnaires was also calculated. Then, the correlation matrix of the variables was examined. Variables with a correlation below 0.3 should be omitted, as they indicate lack of a correlation pattern, and variables with a correlation coefficient above 0.9 indicate a multi co-linearity and should be omitted (Watkins, 2018). Fifty nurses selected by convenience sampling were asked to complete the developed questionnaire; then the correlation matrix of the variables was checked.
2.1.2.4. Construct validity
Exploratory factor analysis was used to describe, classify, and summarize data (considering that the goal was to extract dimensions based on questionnaire items for the first time and due to the limitation of access to sufficient number of samples). In this study, the four criteria of scree plot, eigenvalues greater than 1 %, explained variance by each factor, and rotation methods were used to determine the number of factors of the clinical judgment capability questionnaire in nurses (Courtney, 2019). The criteria used for deleting items were the following: factors that had fewer than three variables or a large number of complex variables that weighed less than 0.5 and items loaded onto more than one factor with similar loadings (Black, 2019). Therefore, the calculated sample size was 181 (Table 2). The Kaiser-Meyer-Olkin (KMO) test for sampling adequacy and the Bartlett's Test of Sphericity were performed before the factor analysis (Kaiser, 1974).
Table 2.
Demographic characteristics of the study participants in the quantitative section (construct validity).
| Variable | n* ( %) | |
|---|---|---|
| Sex | Male | 59 (32.59) |
| Female | 122 (67.41) | |
| Marriage | Single | 40 (22.09) |
| Married | 141 (77.91) | |
| Educational status | Bachelor's of Nursing | 162 (89.50) |
| Master's of Nursing | 19 (10.5) | |
| Age | 38.05 ± 4.67 | |
| Work experience | 13.38 ± 2.10 | |
Number in subgroup.
2.1.2.5. Final reliability
Two methods of internal consistency and stability were used to determine reliability of the questionnaire. To determine internal consistency, 50 nurses completed the questionnaire; then we calculated the Cronbach's alpha coefficient (Youssef et al., 2023). To determine the stability of the questionnaire, the test-retest method was used with 50 nurses and a time interval of 2 weeks (Wang et al., 2021).
2.2. Ethics considerations
The present study was approved by the ethics committee of Jahrom University of Medical Sciences: IR. JUMS. REC.1399.132. Before data collection, all nurses signed an informed consent. The objectives and method of the study were also explained to them, and they were then given sufficient assurance about the confidentiality of the information. The study was based on ethical principles prepared by the Helsinki Declaration and the guidelines of the Ministry of Health and Medical Education.
3. Results
The research findings are presented in qualitative and quantitative parts.
3.1. Part I: Qualitative study
Four main categories were extracted. The characteristics and dimensions of nurses' clinical judgment capability included the following four dimensions:
-
1)
Noticing: nurses pay attention to patients' clinical conditions and reactions to care.
-
2)
Interpreting: nurses interpret and evaluate patients' conditions based on collected objective and subjective data
-
3)
Responding: nurses respond to patients’ needs and the advancement of the nursing profession
-
4)
Reflecting: nurses reflect on their decisions based on the outcomes of nursing interventions.
Next, the initial pool of items was used to develop the questionnaire. From this base, we developed 46 items. Then, after three revisions of the items, overlapping items were modified or deleted, so eight items were removed at this stage. The remaining 38 items entered the second part of the study.
3.2. Part II: Determining psychometric properties (validity and reliability)
3.2.1. 1. Face validity
None of the items was removed, and some items were revised. For example, the item “I hypothesize to find answers to the patient's problems” was revised to “In order to find response to the patient's problems, I consider different hypotheses”. Therefore, at the end of this step, the number of items was 38.
3.2.2. Content validity
No item was removed in the qualitative content validity review. In the CVR assessment, four items were removed due to scores less than 0.75. In the CVI assessment, five items were removed due to scores less than 0.79. Therefore, at the end of this step, 29 items remained.
3.2.3. Initial reliability
The internal consistency of the questionnaire was calculated with Cronbach's alpha coefficient of 0.87. In this step, one item was removed due to its correlation coefficient being less than 0.3. Therefore, at the end of this step, 28 items remained.
3.2.4. Construct validity
The questionnaire developed with the remaining 28 items for construct validity, exploratory factor analysis, and determining the number of factors was completed by 181 nurses. The KMO test value for the factor analysis was .93, and the χ2 value for Bartlett's test of sphericity was 2918.186 (p < .001).
The scree plot showed that four factors were sufficient to explain the factorial structure of the nurses' clinical judgment capability questionnaire. The amount of total variance of four factors was 62.25 %. From the 28 initial items in the construct validity stage, six items were removed due to factor loading less than 0.5. In this way, the final questionnaire for assessing nurses' clinical judgment capability with 22 items and four factors (dimensions) was finalized (Table 3). Considering that the items under the components were the same and the same items loaded on the same factors, the components were named as they were extracted in the qualitative analysis results. Two cross-loading items loaded on the factor with a higher factor loading. All items were set on a Likert scale so that each item was graded on a 5-point scale: 1 = very low, 2 = below average, 3 = average, 4 = above average, and 5 = very high. The range of scores of this questionnaire was 22-110. A higher score indicated better clinical judgment capability of nurses.
Table 3.
Results of principal components analysis of 22 items of clinical judgment capability (N* = 181).
| Subscales | Item | Rotated Component Matrix |
|||
|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | ||
| Noticing | I pay attention to the patient's reaction during care. | 0.651 | |||
| In patient care, I observe the general condition of the patient at first sight. | 0.635 | ||||
| I pay attention to the changes that occur in the patient's clinical condition. | 0.650 | ||||
| I consider patients' culture as important in providing care and pay attention to it. | 0.598 | ||||
| I pay attention to the patient's needs | 0.598 | ||||
| In caring for patients, I pay attention to all the factors affecting the condition of the disease. | 0.541 | ||||
| I pay attention to the patient's interactions with family members for better evaluation. | 0.558 | ||||
| Interpreting | I evaluate the patient's condition based on the collected objective and subjective data. | 0.701 | |||
| In choosing the best solution for the patient's clinical problems, I use the solution that is supported by the majority of the collected data. | 0.723 | ||||
| I evaluate the patient's responses to nursing care. | 0.614 | ||||
| I match the patient's signs and symptoms with the patient's age and physiological conditions. | 0.661 | ||||
| I discuss with colleagues how to care for patients. | 0.513 | ||||
| Responding | In providing clinical care, I take care of patients based on the priority of need. | 0.689 | |||
| I establish good and clear communication with patients. | 0.698 | ||||
| I establish good and clear communication with colleagues (nurses, physicians, etc.). | 0.698 | ||||
| I provide nursing care to the patient based on scientific evidence and documentation. | 0.698 | ||||
| I consider myself committed to progress and promotion in the nursing profession. | 0.698 | ||||
| I constantly update my information about standard care activities. | 0.651 | ||||
| Reflecting | In order to find a response to the patient's problems, I consider different hypotheses. | 0.771 | |||
| By investigating further and rejecting assumptions, I arrive at logical response regarding the patient's condition. | 0.771 | ||||
| I use my experiences for clinical judgment. | 0.763 | ||||
| I share the results of nursing interventions with the patient if needed. | 0.685 | ||||
| Eigenvalue | 5.987 | 3.234 | 1.879 | 1.234 | |
| % of variance | 27.764 | 13.256 | 11.376 | 9.859 | |
Number.
3.2.5. Final reliability
The internal consistency of the questionnaire was obtained by calculating a Cronbach's alpha coefficient of 0.95. The Cronbach's alpha coefficient for four factors is also given separately in Table 4. The stability of the questionnaire was calculated at 0.84, which indicates good stability over time. Also, the intraclass correlation coefficient for four factors is shown separately in Table 4.
Table 4.
The Cronbach's alpha and the intraclass correlation coefficient values for the nurse's clinical judgment capability questionnaire and its factors.
| Factors | Subscales | Number of items | Internal consistency | Stability (intraclass correlation coefficient) |
|---|---|---|---|---|
| 1 | Noticing | 7 | α = 0.87 | 0.83 |
| 2 | Interpreting | 5 | α = 0.83 | 0.78 |
| 3 | Responding | 6 | α = 0.86 | 0.81 |
| 4 | Reflecting | 4 | α = 0.79 | 0.75 |
| Total | 22 | α = 0.95 | 0.84 |
4. Discussion
We reported the development and validation of Iranian nurses' clinical judgment capability questionnaire. The final version of the questionnaire includes 22 items and four dimensions of noticing, interpreting, responding, and reflecting. We showed that the developed questionnaire has acceptable validityand reliability. The Cronbach's alpha coefficient for the questionnaire indicated good reliability. Tanner's (2006) clinical judgment model also included four phases of noticing, interpreting, responding, and reflecting, which provides a basis for clinical judgment questionnaires.
The first dimension of the nurses' clinical judgment capability questionnaire includes noticing, with seven items. The items of this dimension showed that in order to rely on clinical judgment, nurses should pay regular and continuous attention to the symptoms of patients so that they can achieve accurate clinical judgment in diagnosing patients' problems and providing appropriate interventions. One of the dimensions of the Lasater evidence-based guide is noticing, which has three indicators of focused observation, recognizing deviations from expected patterns, and information seeking (Lasater, 2007). The indicators extracted in the Lasater evidence-based guide's noticing dimension align with some items extracted in the present study. In addition, in the present developed questionnaire, things like the patient's culture, needs, interactions with family members, and similar are also considered. Saidi et al. (2014), analyzed the concept of clinical judgment with Rodgers's evolutionary approach and found that clinical judgment in nursing is a complicated process with attributes of intention, observation, data collection, information process, interpretation, prioritization, and inference. Also, in the study conducted by Pouralizadeh et al. (2017), one of the factors affecting students' clinical judgment was introduced under the title of "thoughtful monitoring". Some of its items are aligned with some items of the dimension of noticing in the present study. These findings were consistent with those of the other studies in which focus on observation, patient monitoring, and continuous assessment were introduced as thoughtful influencing factors to initiate the phase of nursing students’ clinical judgment process(Lasater, 2007).
The second dimension of the nurses' clinical judgment capability questionnaire includes interpreting with five items. Nurses use clinical judgment skills to assess patients and the environment and interpret patient information to identify and meet patient needs (Klenke-Borgmann et al., 2020). One of the characteristics of clinical judgment capability is prioritizing and interpreting data using reasoning and cognitive processes (Ludlow et al., 2021). The present study findings are consistent with those of the Tanner (2006) clinical judgment model that considered some cases as the essential measures before the first phase of clinical judgment, including the objective and subjective data related to the status of patients. Yuan et al. (2014) also state that clinical judgment is the process by which nurses recognize subtle changes in clinical situations and interpret what they observe. The interpreting dimension in the Lasater evidence-based guide includes two indicators of prioritizing and understanding of data. The nurses first interpret the data patterns of the patient and then base an intervention plan for the patient based on the interpretation (Lasater, 2007). According to the study of Connor et al. (2023), one of the characteristics of clinical judgment in nursing is the ability to clinically reason with the information and evidence available, which is in line with the interpreting dimension in the present study.
The third dimension of the nurses' clinical judgment capability questionnaire, responding, consists of six items. In fact, at this stage, the nurse reacts to the patients' problems and needs according to the available information, previous experiences, and sufficient nursing skills(Østervang et al., 2022). Gordon et al. (2021), also believe that in clinical judgment, nurses address and respond to patients' needs using scientific evidence, problem solving methods, presenting new ideas, and psychomotor skills. Clinical judgment is a method by which, nurses understand the problems related to patients and respond to their needs with obtaining important information about the patient(Connor et al., 2023). In the Lasater evidence-based guide (2007), there are two dimensions of responding, including clear communication and being skillful, which are aligned with some of the items of the responding dimension in the present study. The items of this dimension refer to the reactions of nurses in response to the needs of patients based on two-way communication, planned interventions, the use of scientific evidence and documentation, and the use of nurses' capabilities in nursing care.
The last dimension of the nurses' clinical judgment capability questionnaire, reflecting, includes four items. The items of this dimension show that nurses think and examine clinical situation using knowledge and deep thinking. Reflection means thoughtful review (Contreras et al., 2020). One of the characteristics of clinical judgment is reflection and critical evaluation. In the reflection phase, nurses independently analyze their interventions and accurately evaluate the possibilities of their decisions (Connor et al., 2023). Shin et al. (2015), define clinical judgment as the art of making decisions that help nurses interpret clinical situations, respond appropriately, and reflect on the effectiveness of interventions. One of the dimensions extracted in the Pouralizadeh et al. (2017) study was continuous comparison and reflection. Reflection-in-action, reflection-on-action, and reflection-beyond-action are the last steps in clinical judgment and an essential factor in the development of clinical knowledge. Connor et al. (2023) showed that clinical judgment is a reflective and reasoning process that draws upon all available data, is informed by an extensive knowledge base, and results in the formation of a clinical conclusion. Also, Connor et al. (2023) showed that one of the characteristics of clinical judgment in nursing is the ability to employ reflective process to actions, which is consistent with the results of the present study.
The existing tools, including the Lasater evidence-based guide, were developed in the simulation environment. In other countries, regarding the use of simulation educational strategies, most studies addressed the effect of this educational strategy on the development of the clinical judgment in nurses (Ashley and Stamp, 2014; Lasater, 2007). In the context of Iran's nursing, nurses and nursing students spend a lot of time in clinical environments to achieve clinical judgment and skills, and simulation is not usually used as a common strategy in the clinical education curriculum (Zaghari Tafreshi, 2013). Therefore, it was necessary to design questionnaire items based on the real clinical environment in Iran's nursing contex.
One of the important components in clinical competence is level of capability in clinical judgment. Therefore, it is necessary to measure this important issue in nurses in order to improve care performance using a standard questionnaire. Development of this questionnaire is a priority in the Iranian nursing education system.
5. Limitations of the study
There are several limitations in this study. First, the participants were selected from one center, which might limit generalizability of findings to nurses in other centers. Another limitation of this study is that the questionnaire was developed based on self-report and self-assessment scales. Finally, this questionnaire may have limitations in distinguishing expert nurses' clinical judgment from that of novice ones.
6. Conclusions
In summary, the nurses' clinical judgment capability questionnaire has satisfactory measurement properties for self-assessment of nurses and thus can be used for evaluating clinical judgment in nurses. Using such a questionnaire, policy makers should be able to identify the current situation in clinical settings and can provide the required resources to develop clinical judgment and improve clinical education.
Consent for publication
Not applicable.
Availability of data and material
Data is not and will not be made available elsewhere. Further data set could be obtained on request if required through corresponding author with email: ali.dehghani2000@gmail.com.
Funding Statement
This study was funded by the Jahrom University of Medical Sciences in Iran.
CRediT authorship contribution statement
Ali Dehghani: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data curation, Writing – original draft, Writing – review & editing, Visualization, Supervision, Project administration, Funding acquisition.
Declaration of competing interest
There was no conflict of interest in this study.
Acknowledgements
We gratefully thank all nurses and expert panel members who participated in this research.
Footnotes
Supplementary material associated with this article can be found in the online version at doi:10.1016/j.ijnsa.2024.100191.
Appendix. Supplementary materials
References
- Abraham W.T., Psotka M.A., Fiuzat M., et al. Standardized definitions for evaluation of heart failure therapies: scientific expert panel from the heart failure collaboratory and academic research consortium. Heart Failure, 2020;8(12):961–972. doi: 10.1016/j.jchf.2020.10.002. [DOI] [PubMed] [Google Scholar]
- Ashley J., Stamp K. Learning to think like a nurse: the development of clinical judgment in nursing students. J. Nurs. Edu. 2014;53(9):519–525. doi: 10.3928/01484834-20140821-14. [DOI] [PubMed] [Google Scholar]
- Benner P. In Practice wisdom. Brill; 2019. Skill acquisition and clinical judgement in nursing practice: towards expertise and practical wisdom; pp. 225–240. [Google Scholar]
- Betts J., Muntean W., Kim D., et al. Building a method for writing clinical judgment items for entry-level nursing exams. J.Appl. Test. Techn. 2019:21–36. [Google Scholar]
- Binti Hassan S.A. Content validity of STEMTIP using CVR method. Int J Acad Res Bus Soc Sci. 2018;8:1118–1125. [Google Scholar]
- Black W., Babin B.J. In The great facilitator: Reflections on the contributions of Joseph F. Hair, Jr. to marketing and business research. Springer International Publishing; Cham: 2019. Multivariate data analysis: Its approach, evolution, and impact; pp. 121–130. [Google Scholar]
- Courtney M.G. Determining the number of factors to retain in EFA: using the SPSS R-menu v2 0 to make more judicious estimations. Practical Ass., Res. Evaluat. 2019;18(1):8. [Google Scholar]
- Cai C.J., Reif E., Hegde N., et al. In Proceedings of the 2019 chi conference on human factors in computing systems. 2019. Human-centered tools for coping with imperfect algorithms during medical decision-making; pp. 1–14. [Google Scholar]
- Chen Q., Su X., Liu S., et al. The relationship between moral sensitivity and professional values and ethical decision-making in nursing students. Nurse Educ. Today. 2021;105 doi: 10.1016/j.nedt.2021.105056. [DOI] [PubMed] [Google Scholar]
- Connor J., Flenady T., Massey D., et al. Clinical judgement in nursing–An evolutionary concept analysis. J. Clin. Nurs. 2023;32(13-14):3328–3340. doi: 10.1111/jocn.16469. [DOI] [PubMed] [Google Scholar]
- Contreras J.A., Edwards-Maddox S., Hall A., et al. Effects of reflective practice on baccalaureate nursing students’ stress, anxiety and competency: An integrative review. Worldviews. Evid. Based. Nurs. 2020;17(3):239–245. doi: 10.1111/wvn.12438. [DOI] [PubMed] [Google Scholar]
- Dehghani A., Makaremnia S., Rahmanian A. Exploring psychological consequences of COVID-19 Pandemic on nurses caring patients with COVID-19: A qualitative study. J. Caring Sci. 2023;12(4):255. doi: 10.34172/jcs.2023.31779. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Dickison P., Haerling K.A., Lasater K. Integrating the National Council of State Boards of Nursing clinical judgment model into nursing educational frameworks. J. Nurs. Edu. 2019;58(2):72–78. doi: 10.3928/01484834-20190122-03. [DOI] [PubMed] [Google Scholar]
- Dörnyei Z., Dewaele J.M. Taylor & Francis; 2022. Book Review Questionnaires in Second Language Research: Construction, Administration, and Processing. [Google Scholar]
- Gordon M.S., Mitchell S.G., Blue T.R., et al. A clinical protocol of a comparative effectiveness trial of extended-release naltrexone versus extended-release buprenorphine with individuals leaving jail. J. Subst. Abuse Treat. 2021;128 doi: 10.1016/j.jsat.2020.108241. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Graneheim U.H., Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ. Today. 2004;24(2):105–112. doi: 10.1016/j.nedt.2003.10.001. [DOI] [PubMed] [Google Scholar]
- Hawkins D., Elder L., Paul R. Rowman & Littlefield; 2019. The thinker's guide to clinical reasoning: based on critical thinking concepts and tools. [Google Scholar]
- Huhn K., Gilliland S.J., Black L.L., et al. Clinical reasoning in physical therapy: a concept analysis. Phys. Ther. 2019;99(4):440–456. doi: 10.1093/ptj/pzy148. [DOI] [PubMed] [Google Scholar]
- Kemerli B., Celik T. Validity and reliability of alexithymia scale. J. European Edu. 2017;5(2):47–55. [Google Scholar]
- Kaiser H.F., Rice J. Little jiffy, mark IV. Educ. Psychol. Meas. 1974;34(1):111–117. [Google Scholar]
- Klenke-Borgmann L., Cantrell M.A., Mariani B. Nurse educators’ guide to clinical judgment: A review of conceptualization, measurement, and development. Nurs. Educ. Perspect. 2020;41(4):215–221. doi: 10.1097/01.NEP.0000000000000669. [DOI] [PubMed] [Google Scholar]
- Kwan J.L., Lo L., Ferguson J., et al. Computerised clinical decision support systems and absolute improvements in care: meta-analysis of controlled clinical trials. BMJ. 2020:370. doi: 10.1136/bmj.m3216. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lasater K. Clinical judgment development: Using simulation to create an assessment rubric. J. Nurs. Edu. 2007;46:496–503. doi: 10.3928/01484834-20071101-04. [DOI] [PubMed] [Google Scholar]
- Ludlow K., Churruca K., Ellis L.A., et al. Decisions and dilemmas: The context of prioritization dilemmas and influences on staff members’ prioritization decisions in residential aged care. Qual. Health Res. 2021;31(7):1306–1318. doi: 10.1177/1049732321998294. [DOI] [PubMed] [Google Scholar]
- Manetti W. Sound clinical judgment in nursing: A concept analysis. Nurs. Forum. 2019;54(1):102–110. doi: 10.1111/nuf.12303. In. [DOI] [PubMed] [Google Scholar]
- Othman S., Steen M., Fleet J. A sequential explanatory mixed methods study design: An example of how to integrate data in a midwifery research project. J. Nurs. Educ. Pract. 2020;11(2):75–89. [Google Scholar]
- Østervang C., Geisler Johansen L., Friis-Brixen A., et al. Experiences of nursing care for patients who self-harm and suggestions for future practices: The perspectives of emergency care nurses. Int. J. Ment. Health Nurs. 2022;31(1):70–82. doi: 10.1111/inm.12933. [DOI] [PubMed] [Google Scholar]
- Polit D., Beck C. Lippincott Williams & Wilkins; 2020. Essentials of nursing research: Appraising evidence for nursing practice. [Google Scholar]
- Pouralizadeh M., Khankeh H.R., Dalvandi A., et al. Designing and psychometric evaluation of questionnaire of influencing factors of nursing students’ clinical judgment: A mixed method study in an iranian context. Iran. Red. Crescent. Med. J. 2017;19(6):1–8. [Google Scholar]
- Pouralizadeh M., Khankeh H.R., Ebadi A., et al. Concept analysis of clinical judgment in nursing students: A hybrid model. Iran. Red. Crescent. Med. J. 2017;19(5) [Google Scholar]
- Sarkhani N., Pashaeypoor S., Negarandeh R., et al. Validity and reliability of the persian version of the short-form adolescent health promotion scale: methodological study. Health Sci. Rep. 2023;6(1):e1063. doi: 10.1002/hsr2.1063. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Seidi J., Alhani F., Salsali M. Clinical Judgment in nursing: a concept analysis using rodgers’ evolutionary method. Hayat. 2014;20(2) [Google Scholar]
- Shin H., Park C.G., Shim K. The Korean version of the Lasater clinical judgment rubric: A validation study. Nurse Educ. Today. 2015;35(1):68–72. doi: 10.1016/j.nedt.2014.06.009. [DOI] [PubMed] [Google Scholar]
- Tanner C.A. Thinking like a nurse: a research-based model of clinical judgment in nursing. J. Nurs. Edu. 2006;45(6):204–211. doi: 10.3928/01484834-20060601-04. [DOI] [PubMed] [Google Scholar]
- Wang W., Liao D., Kang X., et al. Development of a valid Chinese version of the Cumberland ankle instability tool in Chinese-speaking patients with chronic ankle instability disorders. Sci. Rep. 2021;11(1):9747. doi: 10.1038/s41598-021-87848-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Watkins M.W. Exploratory factor analysis: a guide to best practice. J. Black Psychol. 2018;44(3):219–246. [Google Scholar]
- Woo K. Lippincott Williams & Wilkins; 2017. Polit & Beck Canadian essentials of nursing research. [Google Scholar]
- Yang F., Wang Y., Yang C., et al. Improving clinical judgment by simulation: a randomized trial and validation of the Lasater clinical judgment rubric in Chinese. BMC. Med. Educ. 2019;19:1–6. doi: 10.1186/s12909-019-1454-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Youssef N., Saleeb M., Gebreal A., et al. Vol. 11. MDPI; 2023. The internal reliability and construct validity of the evidence-based practice questionnaire (EBPQ): Evidence from healthcare professionals in the Eastern Mediterranean Region; p. 2168. (Healthcare). In. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Yuan H.B., Williams B.A., Man C.Y. Nursing students' clinical judgment in high-fidelity simulation based learning: a quasi-experimental study. J. Nurs. Educ. Pract. 2014;4(5):7. [Google Scholar]
- Zaghari Tafreshi M., Rasouli M., Sajadi M. Simulation in nursing education: A review article. Iran J Med Educ. 2013;12(11):888–894. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data is not and will not be made available elsewhere. Further data set could be obtained on request if required through corresponding author with email: ali.dehghani2000@gmail.com.