clinical reasoning in nursing education

• - Google Chrome

Intended for healthcare professionals

• Access provided by Google Indexer
• My email alerts
• BMA member login
• Username * Password * Forgot your log in details? Need to activate BMA Member Log In Log in via OpenAthens Log in via your institution

Search form

• Advanced search
• Search responses
• Search blogs
• News & Views
• Margaret McCartney:...

Nurses are critical thinkers

Rapid response to:

Margaret McCartney: Nurses must be allowed to exercise professional judgment

• Related content
• Article metrics
• Rapid responses

Rapid Response:

The characteristic that distinguishes a professional nurse is cognitive rather than psychomotor ability. Nursing practice demands that practitioners display sound judgement and decision-making skills as critical thinking and clinical decision making is an essential component of nursing practice. Nurses’ ability to recognize and respond to signs of patient deterioration in a timely manner plays a pivotal role in patient outcomes (Purling & King 2012). Errors in clinical judgement and decision making are said to account for more than half of adverse clinical events (Tomlinson, 2015). The focus of the nurse clinical judgement has to be on quality evidence based care delivery, therefore, observational and reasoning skills will result in sound, reliable, clinical judgements. Clinical judgement, a concept which is critical to the nursing can be complex, because the nurse is required to use observation skills, identify relevant information, to identify the relationships among given elements through reasoning and judgement. Clinical reasoning is the process by which nurses observe patients status, process the information, come to an understanding of the patient problem, plan and implement interventions, evaluate outcomes, with reflection and learning from the process (Levett-Jones et al, 2010). At all times, nurses are responsible for their actions and are accountable for nursing judgment and action or inaction.

The speed and ability by which the nurses make sound clinical judgement is affected by their experience. Novice nurses may find this process difficult, whereas the experienced nurse should rely on her intuition, followed by fast action. Therefore education must begin at the undergraduate level to develop students’ critical thinking and clinical reasoning skills. Clinical reasoning is a learnt skill requiring determination and active engagement in deliberate practice design to improve performance. In order to acquire such skills, students need to develop critical thinking ability, as well as an understanding of how judgements and decisions are reached in complex healthcare environments.

As lifelong learners, nurses are constantly accumulating more knowledge, expertise, and experience, and it’s a rare nurse indeed who chooses to not apply his or her mind towards the goal of constant learning and professional growth. Institute of Medicine (IOM) report on the Future of Nursing, stated, that nurses must continue their education and engage in lifelong learning to gain the needed competencies for practice. American Nurses Association (ANA), Scope and Standards of Practice requires a nurse to remain involved in continuous learning and strengthening individual practice (p.26)

Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgement: A practical approach to outcome-focused thinking. (4th ed.). St Louis: Elsevier

The future of nursing: Leading change, advancing health, (2010). https://campaignforaction.org/resource/future-nursing-iom-report

Levett-Jones, T., Hoffman, K. Dempsey, Y. Jeong, S., Noble, D., Norton, C., Roche, J., & Hickey, N. (2010). The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’ patients. Nurse Education Today. 30(6), 515-520.

NMC (2010) New Standards for Pre-Registration Nursing. London: Nursing and Midwifery Council.

Purling A. & King L. (2012). A literature review: graduate nurses’ preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23–24), 3451–3465

Thompson, C., Aitken, l., Doran, D., Dowing, D. (2013). An agenda for clinical decision making and judgement in nursing research and education. International Journal of Nursing Studies, 50 (12), 1720 - 1726 Tomlinson, J. (2015). Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Medical Education, 15(103)

Competing interests: No competing interests

Clinical Education in Nursing: Current Practices and Trends

• Living reference work entry
• First Online: 04 February 2020
• Cite this living reference work entry

• Marilyn H. Oermann 5 &
• Teresa Shellenbarger 6  

1621 Accesses

4 Citations

This chapter examines current practices in clinical nursing education and intended outcomes of clinical experiences for nursing students. The chapter presents models of clinical nursing education, teaching methods used commonly in clinical settings, and technology to support and enhance learning in clinical settings. The chapter concludes with a broad overview of clinical evaluation.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Institutional subscriptions

Similar content being viewed by others

The Main Elements of Clinical Learning in Healthcare Education

Clinical Education: Origins and Outcomes

Educational Considerations

Altmiller G. Strategies for providing constructive feedback to students. Nurse Educ. 2016;41:118–9.

Article   Google Scholar  

Altmiller G, Armstrong G. 2017 National Quality and safety education for nurses faculty survey results. Nurse Educ. 2017;42:S3–7.

Bates DW, Singh H. Two decades since to err is human: an assessment of progress and emerging priorities in patient safety. Health Aff (Millwood). 2018;37:1736–43.

Beauregard P, Arnaert A, Ponzoni N. Nursing students’ perceptions of using smartphones in the community practicum: a qualitative study. Nurse Educ Today. 2017;53:1–6.

Burbach B, Barnason S, Thompson SA. Using “think aloud” to capture clinical reasoning during patient simulation. Int J Nurs Educ Scholarsh. 2015;12:1–7. https://doi.org/10.1515/ijnes-2014-0044 .

Carter C, Hunt BH, Mukonka PS, Viveash S, Notter J, Toner L. ‘I’ll never be the same’: the impact of an international elective. Br J Nurs. 2019;28:186–92.

Chickering A, Gamson Z. Seven principles for good practice in undergraduate education. AAHE Bull. 1987;39:3–7.

Google Scholar  

Crawford R, Jasonsmith A, Leuchars D, Naidu A, Pool L, Tosswill L, et al. “Feeling part of a team”: a mixed method evaluation of a dedicated education unit pilot programme. Nurse Educ Today. 2018;68:165–71.

Dahlke S, Hannesson T. Clinical faculty management of the challenges of being a guest in clinical settings: an exploratory study. J Nurs Educ. 2016;55:91–5.

Dapremont J, Lee S. Partnering to educate: dedicated education units. Nurse Educ Pract. 2013;13:335–7.

de Castro AB, Dyba N, Cortez ED, Pe Benito GG. Collaborative online international learning to prepare students for multicultural work environments. Nurse Educ. 2019;44:E1–5.

Devereaux Melillo K, Abdallah L, Dodge L, Dowling JS, Prendergast N, Rathbone A, et al. Developing a dedicated education unit in long-term care: a pilot project. Geriatr Nurs. 2014;35:264–71.

Diefenbeck C, Herrman J, Wade G, Hayes E, Voelmeck W, Cowperthwait A, et al. Preparedness for clinical: evaluation of the core elements of the clinical immersion curriculum model. J Prof Nurs. 2015;31:124–32.

Foronda CL, Swoboda SM, Henry MN, Kamau E, Sullivan N, Hudson KW. Student preferences and perceptions of learning from vSIM for Nursing™. Nurse Educ Pract. 2018;33:27–32.

Fowler SM, Knowlton MC, Putnam AW. Reforming the undergraduate nursing clinical curriculum through clinical immersion: a literature review. Nurse Educ Pract. 2018;31:68–76.

Fox J. Creating a dedicated education unit in long-term care. J Gerontol Nurs. 2017;43:23–9.

George LE, Locasto LW, Pyo KA, Cline TW. Effect of the dedicated education unit on nursing student self-efficacy: a quasi-experimental research study. Nurse Educ Pract. 2017;23:48–53.

Giddens JF, Caputi L. Conceptual teaching strategies for clinical education. In: Giddens JF, Caputi LB, Rodgers B, editors. Mastering concept-based teaching. St. Louis: Elsevier; 2020. p. 101–17.

Hannans J. Online clinical post conference: strategies for meaningful discussion using VoiceThread. Nurse Educ. 2019;44:29–33.

Hayden JK, Smiley RA, Alexander M, Kardong-Edgren S, Jeffries PR. The NCSBN national simulation study: a longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. J Nurs Regul. 2014;5:S3–S40.

Hensel D. Typologies of professional identity among graduating baccalaureate-prepared nurses. J Nurs Scholarsh. 2014;46:125–33.

Hensel D, Laux M. Longitudinal study of stress, self-care, and professional identity among nursing students. Nurse Educ. 2014;39:227–31.

Hong S, Yu P. Comparison of the effectiveness of two styles of case-based learning implemented in lectures for developing nursing students’ critical thinking ability: a randomized controlled trial. Int J Nurs Stud. 2017;68:16–24.

Horsley TL, Reed T, Muccino K, Quinones D, Siddall VJ, McCarthy J. Developing a foundation for interprofessional education within nursing and medical curricula. Nurse Educ. 2016;41:234–8.

Interprofessional Education Collaborative. Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative; 2016.

Kavanagh JM, Szweda C. A crisis in competency: the strategic and ethical imperative to assessing new graduate nurses’ clinical reasoning. Nurs Educ Perspect. 2017;38:57–62.

Killingworth E. Facilitate learning in the health care environment. In: Shellenbarger T, editor. Clinical nurse educator competencies: creating an evidence-based practice for academic clinical nurse educators. Washington, DC: National League for Nursing; 2019. p. 21–37.

Kumm S, Godfrey N, Richards V, Hulen J, Ray K. Senior student nurse proficiency: a comparative study of two clinical immersion models. Nurse Educ Today. 2016;44:146–50.

Lafrance T. Exploring the intrinsic benefits of nursing preceptorship: a personal perspective. Nurse Educ Pract. 2018;33:1–3.

Lasater K, Holloway K, Lapkin S, Kelly M, McGrath B, Nielsen A, et al. Do prelicensure nursing students’ backgrounds impact what they notice and interpret about patients? Nurse Educ Today. 2019;78:37–43.

Li S, Ye X, Chen W. Practice and effectiveness of “nursing case-based learning” course on nursing student’s critical thinking ability: a comparative study. Nurse Educ Pract. 2019;36:91–6.

Mackay BJ, Anderson J, Harding T. Mobile technology in clinical teaching. Nurse Educ Pract. 2017;22:1–6.

Maguire DJ, Zambroski CH, Cadena SV. Using a clinical collaborative model for nursing education. Nurse Educ. 2012;37:80–5.

Manetti W. Sound clinical judgment in nursing: a concept analysis. Nurs Forum. 2019;54:102–10.

Missen K, McKenna L, Beauchamp A, Larkins JA. Qualified nurses’ perceptions of nursing graduates’ abilities vary according to specific demographic and clinical characteristics. A descriptive quantitative study. Nurse Educ Today. 2016;45:108–13.

O’Connor S, Andrews T. Mobile technology and its use in clinical nursing education: a literature review. J Nurs Educ. 2015;54:137–44.

O’Connor S, Andrews T. Smartphones and mobile applications (apps) in clinical nursing education: a student perspective. Nurse Educ Today. 2018;69:172–8.

Oermann M, Gaberson K. Evaluation and testing in nursing education. 6th ed. New York: Springer Publishing; 2021.

Oermann MH, Molloy MA, Vaughn J. Use of deliberate practice in teaching in nursing. Nurse Educ Today. 2015;35:535–6.

Oermann MH, Muckler VC, Morgan B. Framework for teaching psychomotor and procedural skills in nursing. J Contin Educ Nurs. 2016;47:278–82.

Oermann M, Shellenbarger T, Gaberson K. Clinical teaching strategies in nursing. 5th ed. New York: Springer Publishing; 2018.

Ostrogorsky TL, Raber AM, McKinley Yoder C, Nielsen AE, Lutz KF, Wros PL. Becoming a nurse: role formation among accelerated baccalaureate students. Nurse Educ. 2015;40:26–30.

Plemmons C, Clark M, Feng D. Comparing student clinical self-efficacy and team process outcomes for a DEU, blended, and traditional clinical setting: a quasi-experimental research study. Nurse Educ Today. 2018;62:107–11.

Quality and Safety Education for Nurses. Website. 2019. Available from: http://qsen.org/

Repo H, Vahlberg T, Salminen L, Papadopoulos I, Leino-Kilpi H. The cultural competence of graduating nursing students. J Transcult Nurs. 2017;28:98–107.

Rhodes ML, Meyers C, Underhill ML. Evaluation outcomes of a dedicated education unit in a baccalaureate nursing program. J Prof Nurs. 2012;28:223–30.

Rusch LM, McCafferty K, Schoening AM, Hercinger M, Manz J. Impact of the dedicated education unit teaching model on the perceived competencies and professional attributes of nursing students. Nurse Educ Pract. 2018;33:90–3.

Shaffer K, Swan BA, Bouchaud M. Designing a new model for clinical education: an innovative approach. Nurse Educ. 2018;43:145–8.

Sherwood G, Zomorodi M. A new mindset for quality and safety: the QSEN competencies redefine nurses’ roles in practice. J Nurs Adm. 2014;44:S10–8.

Skiba DJ. Informatics competencies for nurses revisited. Nurs Educ Perspect. 2016;37:365–7.

Soderstrom NC, Bjork RA. Learning versus performance: an integrative review. Perspect Psychol Sci. 2015;10:176–99.

Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ. 2006;45:204–11.

Thistlethwaite JE, Davies D, Ekeocha S, Kidd JM, MacDougall C, Matthews P, et al. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach. 2012;34:e421–44.

van der Riet P, Levett-Jones T, Courtney-Pratt H. Nursing students’ perceptions of a collaborative clinical placement model: a qualitative descriptive study. Nurse Educ Pract. 2018;30:42–7.

Welch T, Carter M. Deliberate practice and skill acquisition in nursing practice. J Contin Educ Nurs. 2018;49:269–73.

Download references

Author information

Authors and affiliations.

Duke University School of Nursing, Durham, NC, USA

Marilyn H. Oermann

Department of Nursing and Allied Health Professions, Indiana University of Pennsylvania, Indiana, PA, USA

Teresa Shellenbarger

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Marilyn H. Oermann .

Editor information

Editors and affiliations.

Monash University, Clayton, VIC, Australia

Debra Nestel

King's College London, London, UK

Gabriel Reedy

School of Nursing and Midwifery, La Trobe University, Bundoora, VIC, Australia

Lisa McKenna

Manchester Metropoli, Manchester, UK

Suzanne Gough

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Singapore Pte Ltd.

About this entry

Cite this entry.

Oermann, M.H., Shellenbarger, T. (2020). Clinical Education in Nursing: Current Practices and Trends. In: Nestel, D., Reedy, G., McKenna, L., Gough, S. (eds) Clinical Education for the Health Professions. Springer, Singapore. https://doi.org/10.1007/978-981-13-6106-7_10-1

Download citation

DOI : https://doi.org/10.1007/978-981-13-6106-7_10-1

Received : 09 November 2019

Accepted : 22 November 2019

Published : 04 February 2020

Publisher Name : Springer, Singapore

Print ISBN : 978-981-13-6106-7

Online ISBN : 978-981-13-6106-7

eBook Packages : Springer Reference Education Reference Module Humanities and Social Sciences Reference Module Education

• Publish with us

Policies and ethics

• Find a journal
• Track your research

• NCSBN Member Login Submit

Access provided by

Login to your account

If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password

If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password

Download started.

• Academic & Personal: 24 hour online access
• Corporate R&D Professionals: 24 hour online access
• Add To Online Library Powered By Mendeley
• Add To My Reading List
• Export Citation
• Create Citation Alert

An Update on Clinical Judgment in Nursing and Implications for Education, Practice, and Regulation

• Mary Ann Jessee, PhD, RN Mary Ann Jessee Search for articles by this author
• Clinical reasoning
• clinical judgment
• nursing practice
• patient safety
• clinical outcomes

Purchase one-time access:

• For academic or personal research use, select 'Academic and Personal'
• For corporate R&D use, select 'Corporate R&D Professionals'
• Al-Moteri M.O.
• Scopus (26)
• Full Text PDF
• Google Scholar

American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdf

• Virkstis K.
• Scopus (117)
• Pagnucci N.
• Valcarenghi D.
• Bagnasco A.
• Scopus (36)
• Billings D.M.
• Scopus (16)
• Borglund S.
• Parcells D.
• Scopus (152)
• Scopus (62)
• Lefebvre H.
• Scopus (13)
• Brown Tyo M.
• McCurry M.K.
• Scopus (60)
• Cantrell M.A.
• Franklin A.
• Leighton K.
• Scopus (75)
• Cappelletti A.
• Prentice D.
• Scopus (65)
• Chaboyer W.
• Grealish L.
• Scopus (105)
• del Bueno D.
• Dickison P.
• Haerling K.A.
• Scopus (100)
• Scopus (12)
• Dos Reis Dutra C.K.
• de Brito Guirardello E.
• Scopus (29)
• Dreifuerst K.T.
• Scopus (237)
• Facione N.C.
• Facione P.A.
• Sanchez C.A.
• Scopus (316)
• Gonzalez L.
• Hansbrough W.
• Dunker K.S.
• Ostendorf M.
• Scopus (116)
• Hickerson K.A.
• Taylor L.A.
• Terhaar M.F.
• Scopus (73)
• Holder A.G.
• Scopus (20)
• ErkenBrack L.
• Handberry L.
• Scopus (14)
• Kleinknecht-Dolf M.
• Scopus (23)
• Huston C.L.
• Phillips B.
• Jeffries P.
• Scopus (104)
• Ironside P.M.
• McNelis A.M.
• Scopus (96)
• Jessee M.A.
• Scopus (25)
• Tanner C.A.
• Scopus (18)
• Hamilton P.
• Scopus (464)
• Kalisch B.J.
• Landstrom G.L.
• Hinshaw A.S.
• Scopus (436)
• Kantar L.D.
• Scopus (52)
• Kavanagh J.M.
• Sharpnack P.A.
• Scopus (204)
• Scopus (35)
• Klenke-Borgmann L.
• Cantrell M.
• Scopus (381)
• Holloway K.
• Dieckmann N.F.
• Campbell M.
• Nielsen A.E.
• Ostrogorsky T.L.
• Scopus (45)
• Kardong-Edgren S.
• Foisy-Doll C.
• Scopus (43)
• Levett-Jones T.
• Jeong S.Y.-S.
• Norton C.A.
• Scopus (265)
• Scopus (57)
• Merisier S.
• Scopus (27)
• Monagle J.L.
• Dieckmann N.
• Scopus (10)
• Andersen E.
• Scopus (30)
• Scopus (34)
• Phillips N.M.
• Weerasuriya R.
• Scopus (19)
• Saintsing D.
• Gibson L.M.
• Pennington A.W.
• Scopus (79)
• Scopus (227)
• Stephenson J.K.
• Scopus (17)
• Scopus (921)
• Donohue-Porter P.
• Stein Fishbein J.
• Scopus (51)
• Thompson C.
• Scopus (77)
• Tyndall D.E.
• Firnhaber G.C.
• Victor-Chmil J.
• Scopus (91)
• Bjuresäter K.
• Scopus (71)

Article info

The author would like to acknowledge the expertise and guidance of Ann Nielsen, PhD, RN; Janet Monagle, PhD, RN; Lisa Gonzalez, MSN, RN CNE, CCRN-K; and Kathie Lasater, EdD, RN, ANEF, FAAN.

Identification

DOI: https://doi.org/10.1016/S2155-8256(21)00116-2

ScienceDirect

Related articles.

• Download Hi-res image
• Download .PPT
• Access for Developing Countries
• Articles & Issues
• Current Issue
• List of Issues
• Supplements
• For Authors
• Guide for Authors
• Author Services
• Permissions
• Researcher Academy
• Submit a Manuscript
• Journal Info
• About the Journal
• Contact Information
• Editorial Board
• New Content Alerts

The content on this site is intended for healthcare professionals.

• Privacy Policy   
• Terms and Conditions   
• Accessibility   
• Help & Contact

Session Timeout (2:00)

Your session will expire shortly. If you are still working, click the ‘Keep Me Logged In’ button below. If you do not respond within the next minute, you will be automatically logged out.

• Types of Nursing Degrees and Careers
• Licensed Practical Nurse (LPN/LVN)
• Associate Degree in Nursing (ADN)
• Bachelor of Science in Nursing (BSN)
• Master of Science in Nursing (MSN)
• Doctor of Nursing Practice (DNP)
• Nursing Bridge Programs
• Registered Nurse (RN)
• Nurse Practitioner (NP)
• Certified Registered Nurse Anesthetist (CRNA)
• Certified Nurse Midwife (CNM)
• Certified Nursing Assistant (CNA)
• Certified Medical Assistant (CMA)
• Clinical Nurse Specialist (CNS)
• Pediatric Nurse
• Neonatal Nurse
• Critical Care Nurse
• Psychiatric Nurse
• Forensic Nurse
• Flight Nurse
• Travel Nurse
• Public Health Nurse
• Nurse Administration
• Nursing Informatics
• Nursing Instructor
• Nurse Researcher
• Connecticut
• How to Find the Right Nursing Program
• How to Pay for Nursing School
• Is Nursing For Me?
• Online Resources for Nurses
• Paths to Becoming a Registered Nurse
• How to Pass the NCLEX-RN: 7 Key Tips
• News & Advice
• NCLEX Prep Course
• News & Advice

Nurse Insights: How Can Nurses Develop Clinical Judgment?

Written by NursingEducation Staff

May 7, 2024

As healthcare professionals, nurses play a crucial role in patient care. To provide the best care possible, registered nurses (RNs) must have strong clinical judgment skills. In this article, we’ll explore how nurses can develop their clinical judgment through understanding the nursing process and continuous learning and education.

How Can Nurses Develop Clinical Judgment?

In our Nurse Insights series, experienced nurses offer an insider’s perspective on the nursing profession by addressing common questions, challenges, and triumphs of their careers.

Understanding the Nursing Process

The nursing process includes five main steps: assessment, diagnosis, planning, implementation, and evaluation. Critical thinking plays a crucial role in each of these stages. Nurses use critical thinking to gather and analyze data during assessment, identify patient problems during diagnosis, develop effective care plans during planning, make informed decisions during implementation, and evaluate the outcomes of care during evaluation.

The first step of the nursing process involves a comprehensive gathering of information about the patient. As a nurse, you’ll collect data about their physiological, psychological, sociological, and spiritual states. Your critical thinking skills play an important role here as you interpret and prioritize this data to form a comprehensive and holistic picture of your patient’s overall health.

The second step, diagnosis, involves interpreting the information you’ve gathered during the assessment. Here, you will identify the patient’s health problems and risks, and decide on the appropriate nursing diagnosis. Critical thinking in this stage requires you to make evidence-based and logical decisions based on the patient’s symptoms and the data collected.

The planning step includes drafting a tailored care plan to address the nursing diagnoses identified. As a nurse, you would identify patient goals and desired outcomes, and choose appropriate nursing interventions. Your critical thinking skills help you to prioritize these interventions based on the severity and potential impact on the patient’s health.

Implementation

During the implementation stage, you will carry out the outlined care plan. This requires your critical thinking skills to adapt to potential changes in the patient’s condition, and make informed judgments about the course of care should new information or problems arise.

The final step, evaluation, allows you to review the patient’s progress toward the set goals and outcomes. It is a continuous process that enables you to determine if your plan needs to be modified or adjusted. In this step, critical thinking aids you in interpreting the results of your interventions, making necessary adjustments, or acknowledging a completed goal.

Role of Continuous Learning and Education in Clinical Judgment

To develop strong clinical judgment as a nurse, you must commit to continuous learning and skill enhancement. You will often find that new research, techniques, and technology are regularly emerging in healthcare. This constant evolution requires you to update and enhance your knowledge and skills to provide the best care to your patients.

Wisdom is Power

The more knowledge and skill you acquire, the better your ability to analyze situations and make appropriate decisions. Whether it’s learning about a newly recognized syndrome or mastering a new procedure, you’re not just acquiring information or skill for the sake of it. Rather, you’re honing that skill to discern what’s relevant in a patient’s presentation and management, to identify patterns, to predict outcomes, and to effectively intervene.

Uncertainty is Part of the Job

Clinical practice often presents you with uncertain situations. Continuous learning equips you with up-to-date medical knowledge, helping you navigate uncertain situations with confidence. By expanding your educational boundaries and strengthening your problem-solving skills, you’re better prepared to handle unexpected or complex medical cases.

The Evolution of Technology

The rapid growth of technology in healthcare can be overwhelming. By keeping current in your learning, you can ensure you know how to use the latest tools and equipment, understand the newest research, and adapt to changing protocols and standards. Without continuous education, you risk falling behind and not delivering the quality of care your patients deserve.

Beyond Books—The Learning Spectrum

Remember, continuous learning goes beyond formal education. It includes attending workshops, participating in professional networks, self-directed study, and utilizing online resources. Never overlook the informal learning that takes place through your daily interactions with colleagues, mentors, and patients.

Every investment you make in your education propels you toward becoming a highly skilled and competent nurse with top-notch clinical judgment. It’s an ongoing journey and an integral part of your nursing career. So, embrace the challenge, pursue knowledge, and never stop learning.

Incorporating Evidence-Based Practice

Incorporating evidence-based practice (EBP) into your nursing practice requires that you integrate research findings into patient care. Doing this will vastly improve your clinical judgment as it allows for the application of the most up-to-date, patient-specific, and evidence-based information.

Using Research Findings

Research findings are derived from scholarly studies conducted by experts, and they often provide in-depth insights and new approaches to patient care. By reviewing these studies and understanding the outcomes, you can better tailor your patient care measures, leading to increased patient care.

In a practical sense, this could mean adopting new procedures established as effective by research for wound care or adopting a recently proven effective communication technique with dementia patients. Remember to evaluate the validity and reliability of your sources to ensure that this information is credible and beneficial to patient outcomes.

Improving Clinical Judgment

Your clinical judgment, the process by which you interpret and respond to patient needs, changes as you incorporate research findings. With more evidence-based knowledge at hand, you are more capable of identifying symptoms, making accurate diagnoses, and carrying out suitable interventions.

For instance, consider a scenario in which a patient presents with atypical symptoms of a common disease. If you are up to date with recent research demonstrations of these atypical presentations, your clinical judgment in diagnosing and treating may be more precise, thus improving the patient outcome.

Benefits to Patient Care

The core aim of nursing practice is to ensure patient welfare and recovery. Integrating research findings into patient care enhances patient outcomes by employing methods that have been analytically proven to be effective. This could mean quicker recovery times, fewer complications, and an overall increase in patient satisfaction.

Use of Reflective Practice for Improving Clinical Judgment

Reflective practice is a fundamental part of nursing that encourages you to use experiences and observations as valuable learning opportunities. It involves revisiting your actions, decisions, and outcomes, and assessing them critically to discover better methods or strategies.

Reflecting on Actions

As you encounter various patient scenarios, you’ll take a series of actions to address them. Reflecting on these actions, and identifying their effectiveness over time, can help you understand why certain methods work, and why others do not. Consider creating a journal or log of your actions to facilitate this process, ensuring patient confidentiality while doing so.

Assessing Decisions

Every moment in nursing involves decision-making. By taking the time to assess your choices and their rationale, you can better align your decisions with evidence-based practices moving forward. This kind of reflective decision-making forms the backbone of strong nursing judgment skills.

Examining the Outcomes

The results of your decisions and actions are crucial points for reflection. You can learn if the methods you’ve used were effective and adjust your future steps based on these outcomes. A pattern of successful outcomes may point you toward tactics you should continue using, while less successful outcomes can suggest areas where change is needed.

Strengthened Judgment Over Time

Over time, regularly reflecting on your actions, decisions, and outcomes will inevitably improve your clinical judgment. You’ll be able to anticipate patient needs more accurately, adapt to unexpected changes, and foster trust and communication with your patients and colleagues.

When it comes to strengthening your nursing judgment through reflective practice, keep in mind that it’s an ongoing process. It’s okay not to have all the answers right away. Even the most experienced nurses continue to learn and grow through reflective practice.

Role-Play and Simulation as Training Tools

Simulation-based education is a great tool in your nursing career. By engaging in role-play and simulation exercises, you can practice nursing skills, learn how different patient scenarios unfold, and, more importantly, focus on honing your clinical decision-making abilities.

Role-Play as an Active Learning Strategy

Through role-play, you don’t just learn about nursing; you actively participate in it. These exercises immerse you in scenarios requiring you to engage with ‘patients,’ analyze their situations, utilize your knowledge, and decide on appropriate nursing interventions. You learn not only from what goes right but also from the mistakes you make in a safe, controlled environment.

Role-play can also help alleviate the fear of real-world patient encounters by familiarizing yourself with typical patient presentations, effective communication strategies, and appropriate reactions to different scenarios. This active learning strategy enhances your ability to think on your feet, a vital trait for nurses in fast-paced healthcare settings.

Simulation—A Replication of the Real World

Simulation-based (SIM-based) training takes this experience a step further. With the use of high-fidelity mannequins that simulate real patient responses, you get a near real-world experience of nursing care. These mannequins can mimic a wide range of health conditions and complications. They can ‘respond’ to your nursing interventions, and their ‘condition’ can improve or deteriorate based on your actions.

Simulations are often conducted in settings resembling hospital rooms or emergency departments, adding another layer of realism. This immersive environment enhances your understanding of the clinical implications of your decisions. You can then reflect on these simulated experiences, scrutinizing your actions, clinical judgments, and areas for improvement.

Feedback and Debriefing—The Backbone of Improvement

A key factor in both role-play and simulation exercises is the feedback and debriefing process following each scenario. Constructive feedback from your instructor or peers helps identify your areas of improvement, strengthening your clinical decision-making abilities. Debriefings not only focus on your actions but also on the decision-making process leading to those actions, fortifying your critical thinking skills.

In conclusion, role-play and simulations are not just about mastering nursing procedures. They’re about replicating the unpredictability and critical decision-making involved in nursing, preparing you to become an effective nurse.

Cultivating Emotional Intelligence in Nursing Practice

Emotional intelligence is fundamental in nursing as it deeply resonates with patient care. It is the ability to recognize, understand, and manage our own emotions and the emotions of others. This helps in establishing a beneficial nurse-patient relationship, making it easier for you to convey empathy for your patients’ needs, fears, and concerns. Showing empathy not only offers comfort to patients, but also provides insights into their emotional state, aiding in your assessment and treatment decisions.

Emotional intelligence can be categorized into five areas:

• Self-Awareness: Recognizing your own emotions and how they impact your actions.
• Self-Regulation: Managing your impulses and emotions and adapting to changing circumstances.
• Motivation: The drive to achieve beyond expectations.
• Empathy: Understanding and sharing the feelings of others.
• Social Skills: Managing relationships to get along with others.

Among these, empathy and social skills are particularly crucial in patient care as they enable you to effectively communicate and collaborate with patients, their families, and the healthcare team.

The Role of Emotional Intelligence in Clinical Decision-Making

When it comes to making sound clinical decisions, emotional intelligence allows you to balance both the emotional and the factual aspects of the situation. During intense clinical scenarios where patients are experiencing distress, your ability to understand and manage emotions can help you remain calm, think clearly, and make rational decisions.

You can practice active listening when patients share their feelings or concerns. This gives you valuable insights into the patients’ perspectives which, along with the factual clinical information, can contribute to effective care planning and decision-making.

Moreover, being emotionally intelligent helps manage the stress that comes with the job. It enables you to effectively handle demanding situations, ensuring your decision-making is not hampered by your emotional state.

Emotional intelligence can be fostered and elevated through continuous education, workshops, and regular self-reflection. Focusing on improving your emotional intelligence will genuinely enhance not only your nursing practice, but the overall healthcare experience for your patients.

Our Commitment to Accuracy

NursingEducation strives to provide information that is up-to-date and unbiased. By engaging professionals from multiple healthcare perspectives, we ensure our content contains accurate information that helps our readers.

We have combined decades of experience teaching, publishing research, and working with patients in all fields of medicine to create accurate and straightforward online education. Once written, each article undergoes a rigorous peer-review process to bring you the highest quality, most comprehensive content possible.

Our writers receive feedback from reviewers to clarify content, prevent misleading statements, and identify areas that would benefit from more information. Our subject matter experts and reviewers generally work full-time in their professions and work for NursingEducation part-time.

How Can a New Nurse Manage Stress and Burnout?

Read Article

Do Credits From Nursing School Ever Expire?

How Do Nurses Handle Professional Boundaries?

Looking to obtain your nursing degree online.

If you're seeking to gain your pre-licensure degree or advance your professional path, the tuition may be more reasonable than you think. Discover the nursing program that's perfect for you!

Nursing Careers

Nursing degrees.

• Licensed Practical Nurse (LPN)
• Doctorate of Nursing Practice (DNP)
• NCLEX Qbank
• NCLEX Pretest
• NCLEX Categories
• NCLEX Preparation

© 2024 NursingEducation. All Rights Reserved.

• Open access
• Published: 16 May 2024

Competency gap among graduating nursing students: what they have achieved and what is expected of them

• Majid Purabdollah 1 , 2 ,
• Vahid Zamanzadeh 2 , 3 ,
• Akram Ghahramanian 2 , 4 ,
• Leila Valizadeh 2 , 5 ,
• Saeid Mousavi 2 , 6 &
• Mostafa Ghasempour 2 , 4  

BMC Medical Education volume  24 , Article number:  546 ( 2024 ) Cite this article

116 Accesses

Metrics details

Nurses’ professional competencies play a significant role in providing safe care to patients. Identifying the acquired and expected competencies in nursing education and the gaps between them can be a good guide for nursing education institutions to improve their educational practices.

In a descriptive-comparative study, students’ perception of acquired competencies and expected competencies from the perspective of the Iranian nursing faculties were collected with two equivalent questionnaires consisting of 85 items covering 17 competencies across 5 domains. A cluster sampling technique was employed on 721 final-year nursing students and 365 Iranian nursing faculties. The data were analyzed using descriptive statistics and independent t-tests.

The results of the study showed that the highest scores for students’ acquired competencies and nursing faculties’ expected competencies were work readiness and professional development, with mean of 3.54 (SD = 0.39) and 4.30 (SD = 0.45), respectively. Also, the lowest score for both groups was evidence-based nursing care with mean of 2.74 (SD = 0.55) and 3.74 (SD = 0.57), respectively. The comparison of competencies, as viewed by both groups of the students and the faculties, showed that the difference between the two groups’ mean scores was significant in all 5 core-competencies and 17 sub-core competencies ( P  < .001). Evidence-based nursing care was the highest mean difference (mean diff = 1) and the professional nursing process with the lowest mean difference (mean diff = 0.70).

The results of the study highlight concerns about the gap between expected and achieved competencies in Iran. Further research is recommended to identify the reasons for the gap between the two and to plan how to reduce it. This will require greater collaboration between healthcare institutions and nursing schools.

Peer Review reports

Introduction| Background

Nursing competence refers to a set of knowledge, skills, and behaviors that are necessary to successfully perform roles or responsibilities [ 1 ]. It is crucial for ensuring the safe and high-quality care of patients [ 2 , 3 , 4 , 5 ]. However, evaluating nursing competence is challenging due to the complex, dynamic, and multi factorial nature of the clinical environment [ 3 ]. The introduction of nursing competencies and their assessment as a standard measure of clinical performance at the professional level has been highlighted by the Association of American Colleges of Nursing [ 6 , 7 ]. As a result, AACN (2020) introduces competence assessment as an emerging concept in nursing education [ 7 ].

On the other hand, the main responsibility of nursing education is to prepare graduates who have the necessary competencies to provide safe and quality care [ 3 ]. Although it is believed that it is impossible to teach everything to students, acquiring some competencies requires entering a real clinical setting and gaining work experience [ 8 ]. However, nursing students are expected to be competent to ensure patient safety and quality of care after graduation [ 9 ]. To the extent that the World Health Organization (WHO), while expressing concern about the low quality of nursing education worldwide, has recommended investing in nursing education and considers that the future to require nurses who are theoretically and clinically competent [ 5 ]. Despite efforts, the inadequate preparation of newly graduated nursing students and doubts about the competencies acquired in line with expectations to provide safe care for entering the nursing setting have become a global concern [ 10 , 11 , 12 , 13 ]. The results of studies in this field are different. The results of Amsalu et al. showed that the competence of newly graduated nursing students to provide quality and safe care was not satisfactory [ 14 ]. Some studies have also highlighted shortcomings in students’ “soft” skills, such as technical competency, critical thinking, communication, teamwork, helping roles, and professionalism [ 15 ]. Additionally, prior research has indicated that several nursing students have an unrealistic perception of their acquired competencies before entering the clinical setting and they report a high level of competence [ 2 ]. In other study, Hickerson et al. showed that the lack of preparation of nursing students is associated with an increase in patient errors and poor patient outcomes [ 16 ]. Some studies also discussed nursing competencies separately; Such as patient safety [ 17 ], clinical reasoning [ 18 ], interpersonal communication [ 19 ], and evidence-based care competence [ 20 ].

On the other hand, the growing need for safe nursing care and the advent of new educational technologies, the emergence of infectious diseases has increased the necessity of nursing competence. As a result, the nursing profession must be educated to excellence more than ever before [ 5 , 21 , 22 ]. Therefore, the self-assessment of students’ competence levels as well as the evaluation of nursing managers about the competencies expected from them is an essential criterion for all healthcare stakeholders, educators, and nursing policymakers to ensure the delivery of safe, and effective nursing care [ 9 , 23 , 24 ].

However, studies of nurse managers’ perceptions of the competence of newly graduated nursing students are limited and mostly conducted at the national level. Hence, further investigation is needed in this field [ 25 , 26 ]. Some other studies have been carried out according to the context and the needs of societies [ 3 , 26 , 27 , 28 ]. The results of some other studies in the field of students’ self-assessment of perceived competencies and managers’ and academic staff’s assessment of expected competency levels are different and sometimes contradictory, and there is the “academic-clinical gap” between expected and achieved competencies [ 25 , 29 , 30 ]. A review of the literature showed that this gap has existed for four decades, and the current literature shows that it has not changed much over time. The academe and practice settings have also been criticized for training nurses who are not sufficiently prepared to fully engage in patient care [ 1 ]. Hence, nursing managers must understand the expected competencies of newly graduated students, because they have a more complete insight into the healthcare system and the challenges facing the nursing profession. Exploration of these gaps can reveal necessities regarding the work readiness of nursing graduates and help them develop their competencies to enter the clinical setting [ 1 , 25 ].

Although research has been carried out on this topic in other countries, the educational system in those countries varies from that of Iran’s nursing education [ 31 , 32 ]. Iran’s nursing curriculum has tried to prepare nurses who have the necessary competencies to meet the care needs of society. Despite the importance of proficiency in nursing education, many nursing graduates often report feeling unprepared to fulfill expected competencies and they have deficiencies in applying their knowledge and experience in practice [ 33 ]. Firstly, the failure to define and identify the expected competencies in the nursing curriculum of Iran led to the absence of precise and efficient educational objectives. Therefore, it is acknowledged that the traditional nursing curriculum of Iran focuses more on lessons organization than competencies [ 34 ]. Secondly, insufficient attention has been given to the scheduling, location, and level of competencies in the nursing curriculum across different semesters [ 35 ]. Thirdly, the large volume of content instead of focusing on expected competencies caused nursing graduates challenged to manage complex situations [ 36 ]. Therefore, we should not expect competencies such as critical thinking, clinical judgment, problem-solving, decision-making, management, and leadership from nursing students and graduates in Iran [ 37 ]. Limited research has been conducted in this field in Iran. Studies have explored the cultural competence of nursing students [ 38 ] and psychiatric nurses [ 39 ]. Additionally, the competence priorities of nurses in acute care have been investigated [ 40 ], as well as the competency dimensions of nurses [ 41 ].

In Iran, after receiving the diploma, the students participate in a national exam called Konkur. Based on the results of this exam, they enter the field of nursing without conducting an aptitude test interview and evaluating individual and social characteristics. The 4-year nursing curriculum in Iran has 130 units including 22 general, 54 specific, 15 basic sciences, and 39 internship units. In each semester, several workshops are held according to the syllabus [ 42 ]. Instead of the expected competencies, a list of general competencies is specified as learning outcomes in the program. Accepted students based on their rank in the exam and their choice in public and Islamic Azad Universities (non-profit), are trained with a common curriculum. Islamic Azad Universities are not supported by government funding and are managed autonomously, this problem limits the access to specialized human resources and sufficient educational fields, and the lower salaries of faculty members in Azad Universities compared to the government system, students face serious challenges. Islamic Azad Universities must pay exorbitant fees to medical universities for training students in clinical departments and medical training centers, doubling these Universities’ financial problems. In some smaller cities, these financial constraints cause students to train in more limited fields of clinical training and not experience much of what they have learned in the classroom in practice and the real world of nursing. The evaluation of learners in the courses according to the curriculum is based on formative and summative evaluation with teacher-made tests, checklists, clinical assignments, conferences, and logbooks. The accreditation process of nursing schools includes two stages internal evaluation, which is done by surveying students, professors and managers of educational groups, and external accreditation is done by the nursing board. After completing all their courses, to graduate, students must participate in an exam called “Final”, which is held by each faculty without the supervision of an accreditation institution, the country’s assessment organization or the Ministry of Health, and obtain at least a score of 10 out of 20 to graduate.

Therefore, we conducted this comprehensive study as the first study in Iran to investigate the difference between the expected and perceived competence levels of final year nursing students. The study’s theoretical framework is based on Patricia Benner’s “From Novice to Expert” model [ 43 ].

Materials and methods

The present study had the following three objectives:

Determining self-perceived competency levels from the perspective of final year nursing students in Iran.

Determining expected levels of competency from the perspective of nursing faculties in Iran.

To determine the difference between the expected competencies from the perspective of nursing faculties and the achieved competencies from the perspective of final-year nursing students.

This study is a descriptive-comparative study.

First, we obtained a list of all nursing schools in the provinces of Iran from the Ministry of Health ( n  = 31). From 208 Universities, 72 nursing schools were randomly selected using two-stage cluster sampling. Among the selected faculties, we chose 721 final-year nursing students and 365 nursing faculties who met the eligibility criteria for the study. Final-year nursing students who consented to participate in the study were selected. Full-time faculty members with at least 2 years of clinical experience and nurse managers with at least 5 years of clinical education experience were also included. In this study, nursing managers, in addition to their educational roles in colleges, also have managerial roles in the field of nursing. Some of these roles include nursing faculty management, nursing board member, curriculum development and review, planning and supervision of nursing education, evaluation, and continuous improvement of nursing education. The selection criteria were based on the significant role that managers play in nursing education and curriculum development [ 44 ]. Non-full-time faculty members and managers without clinical education experience were excluded from the study.

The instrument used in this study is a questionnaire developed and psychometrically tested in a doctoral nursing dissertation [ 45 ]. To design the tool, the competencies expected of undergraduate nursing students in Iran and worldwide were first identified through a scoping review using the methodology recommended by the Joanna Briggs Institute (JBI) and supported by the PAGER framework. Summative content analysis by Hsieh and Shannon (2005) was used for analysis, which included: counting and comparing keywords and content, followed by interpretation of textual meaning. In the second step, the results of the first step were used to create tool statements. Then the validity of the instrument was checked by face validity, content validity (determination of the ratio and index of content validity), and validity of known groups. Its reliability was also checked by internal consistency using Cronbach’s alpha method and stability using the test-retest method. The competency questionnaire comprises 85 items covering 17 competencies across 5 domains: “individualized care” (4 competencies with 21 items), “evidence-based nursing care” (2 competencies with 10 items), “professional nursing process” (3 competencies with 13 items), “nursing management” (2 competencies with 16 items), and “work readiness and professional development” (6 competencies with 25 items) [ 45 ]. “The Bondy Rating Scale was utilized to assess the competency items, with ratings ranging from 1 (Dependent) to 5 (Independent) on a 5-point Likert scale [ 46 ]. The first group (nursing students) was asked to indicate the extent to which they had acquired each competency. The second group (nursing faculties) was asked to specify the level to which they expected nursing students to achieve each competency.

Data collection

First, the researcher contacted the deans and managers of the selected nursing schools by email to obtain permission. After explaining the aims of the study and the sampling method, we obtained the telephone number of the representative of the group of final year nursing students and also the email of the faculty members. The representative of the student group was then asked to forward the link to the questionnaire to 10 students who were willing to participate in the research. Informed consent for students to participate in the online research was provided through the questionnaires, while nursing faculty members who met the eligibility criteria for the study received an informed consent form attached to the email questionnaire. The informed consent process clarified the study objectives and ensured anonymity of respondent participation in the research, voluntary agreement to participate and the right to revoke consent at any time. An electronic questionnaire was then sent to 900 final year nursing students and 664 nursing faculties (from 4 March 2023 to 11 July 2023). Reminder emails were sent to nursing faculty members three times at two-week intervals. The attrition rate in the student group was reported to be 0 (no incomplete questionnaires). However, four questionnaires from nursing faculty members were discarded because of incomplete responses. Of the 900 questionnaires sent to students and 664 sent to nursing faculties, 721 students and 365 nursing faculty members completed the questionnaire. The response rates were 79% and 66% respectively.

Data were analyzed using SPSS version 22. Frequencies and percentages were used to report categorical variables and mean and standard deviations were used for quantitative variables. The normality of the quantitative data was confirmed using the Shapiro-Wilk and Skewness tests. An independent t-test was used for differences between the two groups.

Data analysis revealed that out of 721 students, 441 (61.20%) was female. The mean and deviation of the students’ age was 22.50 (SD = 1.21). Most of the students 577 (80%) were in their final semester. Also, of the total 365 faculties, the majority were female 253 (69.31%) with a mean of age 44.06 (SD = 7.46) and an age range of 22–65. The academic rank of most nursing faculty members 156 (21.60%) was assistant professor (Table  1 ).

The results of the study showed that in both groups the highest scores achieved by the students and expected by the nursing faculty members were work readiness and professional development with a mean and standard deviation of 3.54 (0.39) and 4.30 (0.45) respectively. The lowest score for both groups was also evidence-based nursing care with a mean and standard deviation of 2.74 (0.55) for students and 3.74 (0.57) for nursing faculty members (Table  2 ).

Also, the result of the study showed that the highest expected competency score from the nursing faculty members’ point of view was the safety subscale. In other words, faculty members expected nursing students to acquire safety competencies at the highest level and to be able to provide safe care independently according to the rating scale (Mean = 4.51, SD = 0.45). The mean score of the competencies achieved by the students was not above 3.77 in any of the subscales and the highest level of competency achievement according to self-report of students was related to safety competencies (mean = 3.77, SD = 0.51), preventive health services (mean = 3.69, SD = 0.79), values and ethical codes (mean = 3.67, SD = 0.77), and procedural/clinical skills (mean = 3.67, SD = 0.71). The other competency subscales from the perspective of the two groups are presented in Table  3 , from highest to lowest score.

The analysis of core competencies achieved and expected from both students’ and nursing faculty members’ perspectives revealed that, firstly, there was a significant difference between the mean scores of the two groups in all five core competencies ( P  < .001) and that the highest mean difference was related to evidence-based care with mean diff = 1 and the lowest mean difference was related to professional care process with mean diff = 0.70 (Table  4 ).

Table  5 indicates that there was a significant difference between the mean scores achieved by students and nursing faculty members in all 5 core competencies and 17 sub-core Competencies ( p  < .001).

The study aimed to determine the difference between nursing students’ self-perceived level of competence and the level of competence expected of them by their nursing faculty members. The study results indicate that students scored highest in work readiness and professional development. However, they were not independent in this competency and required support. The National League for Nursing (NLN) recognizes nursing professional development as the goal of nursing education programs [ 47 ] However, Aguayo-Gonzalez [ 48 ] believes that the appropriate time for professional development is after entering a clinical setting. This theme includes personal characteristics, legality, clinical/ procedural skills, patient safety, preventive health services, and mentoring competence. Personality traits of nursing students are strong predictors of coping with nursing stress, as suggested by Imus [ 49 ]. These outcomes reflect changes in students’ individual characteristics during their nursing education. Personality changes, such as the need for patience and persistence in nursing care and understanding the nurse identity prepare students for the nursing profession, which is consistent with the studies of Neishabouri et al. [ 50 ]. Although the students demonstrated a higher level of competence in this theme, an examination of the items indicates that they can still not adapt to the challenges of bedside nursing and to use coping techniques. This presents a concerning issue that requires attention and resolution. Previous studies have shown that nursing education can be a very stressful experience [ 51 , 52 , 53 ].

Of course, there is no consensus on the definition of professionalism and the results of studies in this field are different. For example, Akhtar et al. (2013) identified common viewpoints about professionalism held by nursing faculty and students, and four viewpoints emerged humanists, portrayers, facilitators, and regulators [ 54 ]. The findings of another study showed that nursing students perceived vulnerability, symbolic representation, role modeling, discontent, and professional development are elements that show their professionalism [ 55 ]. The differences indicate that there may be numerous contextual variables that affect individuals’ perceptions of professionalism.

The legal aspects of nursing were the next item in this theme that students needed help with. The findings of studies regarding the legal competence of newly graduated nursing students are contradictory reported that only one-third of nurse managers were satisfied with the legal competence of newly graduated nursing students [ 56 , 57 ]. Whereas the other studies showed that legality was the highest acquired competence for newly graduated nursing students [ 58 , 59 ]. However, the results of this study indicated that legality may be a challenge for newly graduated nursing students. Benner [ 43 ] highlighted the significant change for new graduates in that they now have full legal and professional responsibility for the patient. Tong and Epeneter [ 60 ] also reported that facing an ethical dilemma is one of the most stressful factors for new graduates. Therefore, the inexperience of new graduates cannot reduce the standard of care that patients expect from them [ 60 ]. Legal disputes regarding the duties and responsibilities of nurses have increased with the expansion of their roles. This is also the case in Iran. Nurses are now held accountable by law for their actions and must be aware of their legal obligations. To provide safe healthcare services, it is essential to know of professional, ethical, and criminal laws related to nursing practice. The nursing profession is accountable for the quality of services delivered to patients from both professional and legal perspectives. Therefore, it is a valuable finding that nurse managers should support new graduates to better deal with ethical dilemmas. Strengthening ethical education in nursing schools necessitates integrating real cases and ethical dilemmas into the curriculum. Especially, Nursing laws are missing from Iran’s undergraduate nursing curriculum. By incorporating authentic case studies drawn from clinical practice, nursing schools provide students with opportunities to engage in critical reflection, ethical analysis, and moral deliberation. These real cases challenge students to apply ethical principles to complex and ambiguous situations, fostering the development of ethical competence and moral sensitivity. Furthermore, ethical reflection and debriefing sessions during clinical experiences enable students to discuss and process ethical challenges encountered in practice, promoting self-awareness, empathy, and professional growth. Overall, by combining theoretical instruction with practical application and the use of real cases, nursing schools can effectively prepare future nurses to navigate ethical dilemmas with integrity and compassion.

However, the theme of evidence-based nursing care was the lowest scoring, indicating that students need help with this theme. The findings from studies conducted in this field are varied. A limited number of studies reported that nursing students were competent to implement evidence-based care [ 61 ], while other researchers reported that nursing students’ attitudes toward evidence-based care to guide clinical decisions were largely negative [ 20 , 62 ]. The principal barriers to implementing evidence-based care are lack of authority to change patient care policy, slow dissemination of evidence and lack of time at the bedside to implement evidence [ 10 ], and lack of knowledge and awareness of the process of searching databases and evaluating research [ 63 ]. While the European Higher Education Area (EHEA) framework and the International Council of Nurses Code of Ethics introduce the ability to identify, critically appraise, and apply scientific information as expected learning outcomes for nursing students [ 64 , 65 ], the variation in findings highlights the complexity of the concept of competence and its assessment [ 23 ]. Evidence-Based Nursing (EBN) education for nursing students is most beneficial when it incorporates a multifaceted approach. Interactive workshops play a crucial role, providing students with opportunities to critically appraise research articles, identify evidence-based practices, and apply them to clinical scenarios. Simulation-based learning further enhances students’ skills by offering realistic clinical experiences in a safe environment. Additionally, clinical rotations offer invaluable opportunities for students to observe and participate in evidence-based practices under the guidance of experienced preceptors. Journal clubs foster a culture of critical thinking and ongoing learning, where students regularly review and discuss current research articles. Access to online resources such as databases and evidence-based practice guidelines allows students to stay updated on the latest evidence and best practices. To bridge the gap between clinical practice and academic theory, collaboration between nursing schools and healthcare institutions is essential. This collaboration can involve partnerships to create clinical learning environments that prioritize evidence-based practice, inter professional education activities to promote collaboration across disciplines, training and support for clinical preceptors, and continuing education opportunities for practicing nurses to strengthen their understanding and application of EBN [ 66 ]. By implementing these strategies, nursing education programs can effectively prepare students to become competent practitioners who integrate evidence-based principles into their clinical practice, ultimately improving patient outcomes.

The study’s findings regarding the second objective showed that nursing faculty members expected students to achieve the highest level of competence in work readiness and professional development, and the lowest in evidence-based nursing care competence. The results of the studies in this area revealed that there is a lack of clarity about the level of competence of newly graduated nursing students and that confusion about the competencies expected of them has become a major challenge [ 13 , 67 ]. Evidence of nurse managers’ perceptions of newly graduated nursing student’s competence is limited and rather fragmented. There is a clear need for rigorous empirical studies with comprehensive views of managers, highlighting the key role of managers in the evaluation of nurse competence [ 1 , 9 ]. Some findings also reported that nursing students lacked competence in primary and specialized care after entering a real clinical setting [ 68 ] and that nursing managers were dissatisfied with the competence of students [ 30 ].

The results of the present study on the third objective confirmed the gap between expected and achieved competence requirements. The highest average difference was related to evidence-based nursing care, and the lowest mean difference was related to the professional nursing process. The findings from studies in this field vary. For instance, Brown and Crookes [ 13 ] reported that newly graduated nursing students were not independent in at least 26 out of 30 competency domains. Similar studies have also indicated that nursing students need a structured program after graduation to be ready to enter clinical work [ 30 ]. It can be stated that the nursing profession does not have clear expectations of the competencies of newly graduated nursing students, and preparing them for entry into clinical practice is a major challenge for administrators [ 13 ]. These findings can be explained by the Duchscher transition shock [ 69 ]. It is necessary to support newly graduated nursing students to develop their competence and increase their self-confidence.

The interesting but worrying finding was the low expectations of faculty members and the low scores of students in the theme of evidence-based care. However, nursing students need to keep their competencies up to date to provide safe and high-quality care. The WHO also considers the core competencies of nurse educators to be the preparation of effective, efficient, and skilled nurses who can teach the evidence-based learning process and help students apply it clinically [ 44 ]. The teaching of evidence-based nursing care appears to vary across universities, and some clinical Faculties do not have sufficient knowledge to support students. In general, it can be stated that the results of the present study are in line with the context of Iran. Some of the problems identified include a lack of attention to students’ academic talent, a lack of a competency-based curriculum, a gap between theory and clinical practice, and challenges in teaching and evaluating the achieved competencies [ 42 ].

Strengths and limitations

The study was conducted on a national level with a sizable sample. It is one of the first studies in Iran to address the gap between students’ self-perceived competence levels and nursing faculty members’ expected competency levels. Nevertheless, one of the limitations of the study is the self-report nature of the questionnaire, which may lead to social desirability bias. In addition, the COVID-19 pandemic coinciding with the student’s first and second years could potentially impact their educational quality and competencies. The limitations established during the outbreak negatively affected the nursing education of students worldwide.

Acquiring nursing competencies is the final product of nursing education. The current study’s findings suggest the existence of an academic-practice gap, highlighting the need for educators, faculty members, and nursing managers to collaborate in bridging the potential gap between theory and practice. While nursing students were able to meet some expectations, such as value and ethical codes, there is still a distance between expectations and reality. Especially, evidence-based care was identified as one of the weaknesses of nursing students. It is recommended that future research investigates the best teaching strategies and more objective assessments of competencies. The findings of this study can be used as a guide for the revision of undergraduate nursing education curricula, as well as a guide for curriculum development based on the development of competencies expected of nursing students. Nursing managers can identify existing gaps and plan to fill them and use them for the professionalization of students. This requires the design of educational content and objective assessment tools to address these competencies at different levels throughout the academic semester. This significant issue necessitates enhanced cooperation between healthcare institutions and nursing schools. Enhancing nursing education requires the implementation of concrete pedagogical strategies to bridge the gap between theoretical knowledge and practical skills. Simulation-based learning emerges as a pivotal approach, offering students immersive experiences in realistic clinical scenarios using high-fidelity simulators [ 70 ]. Interprofessional education (IPE) is also instrumental, in fostering collaboration among healthcare professionals and promoting holistic patient care. Strengthening clinical preceptorship programs is essential, with a focus on providing preceptors with formal training and ongoing support to facilitate students’ clinical experiences and transition to professional practice [ 71 ]. Integrating evidence-based practice (EBP) principles throughout the curriculum cultivates critical thinking and inquiry skills among students, while technology-enhanced learning platforms offer innovative ways to engage students and support self-directed learning [ 72 ]. Diverse and comprehensive clinical experiences across various healthcare settings ensure students are prepared for the complexities of modern healthcare delivery. By implementing these practical suggestions, nursing education programs can effectively prepare students to become competent and compassionate healthcare professionals.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Huston C, et al. The academic-practice gap: strategies for an enduring problem . In nursing forum . Wiley Online Library; 2018.

Meretoja R, Isoaho H, Leino-Kilpi H. Nurse competence scale: development and psychometric testing. J Adv Nurs. 2004;47(2):124–33.

Article   Google Scholar  

Järvinen T, et al. Nurse educators’ perceptions of factors related to the competence of graduating nursing students. Nurse Educ Today. 2021;101:104884.

Satu KU, et al. Competence areas of nursing students in Europe. Nurse Educ Today. 2013;33(6):625–32.

World Health Organization. State of the world’s nursing 2020: investing in education, jobs and leadership. 2020 [cited 12 June 2023; https://www.who.int/publications-detail-redirect/9789240003279 .

Lee W-H, Kim S, An J. Development and evaluation of korean nurses’ core competency scale (KNCCS) 2017.

American Association of Colleges of Nursing. The essentials: core competencies for professional nursing education… 2020 [cited 2023; https://www.aacnnursing.org/Portals/0/PDFs/Publications/Essentials-2021.pdf .

Gardulf A, et al. The Nurse Professional competence (NPC) scale: self-reported competence among nursing students on the point of graduation. Nurse Educ Today. 2016;36:165–71.

Kajander-Unkuri S, et al. The level of competence of graduating nursing students in 10 European countries-comparison between countries. Nurs Open. 2021;8(3):1048–62.

Labrague LJ et al. A Multicountry Study on Nursing Students’ Self-Perceived Competence and Barriers to Evidence‐Based Practice 2019. 16(3): pp. 236–246.

Visiers-Jiménez L, et al. Clinical learning environment and graduating nursing students’ competence: a multi-country cross-sectional study. Nurs Health Sci. 2021;23(2):398–410.

Herron EK. New graduate nurses’ preparation for recognition and prevention of failure to rescue: a qualitative study. J Clin Nurs. 2018;27(1–2):e390–401.

Google Scholar  

Brown RA, Crookes PA. What are the ‘necessary’ skills for a newly graduating RN? Results of an Australian survey. BMC Nurs. 2016;15:23.

Amsalu B, et al. Clinical practice competence of Mettu University nursing students: a cross-sectional study. Adv Med Educ Pract. 2020;11:791–8.

Song Y, McCreary LL. New graduate nurses’ self-assessed competencies: an integrative review. Nurse Educ Pract. 2020;45:102801.

Hickerson KA, Taylor LA, Terhaar MF. The Preparation-Practice gap: an Integrative Literature Review. J Contin Educ Nurs. 2016;47(1):17–23.

Huang FF, et al. Self-reported confidence in patient safety competencies among Chinese nursing students: a multi-site cross-sectional survey. BMC Med Educ. 2020;20(1):32.

Hong S et al. A Cross-Sectional Study: What Contributes to Nursing Students’ Clinical Reasoning Competence? Int J Environ Res Public Health, 2021. 18(13).

Mcquitty DJPE, Counseling. Teaching interpersonal communication concepts to increase awareness and reduce health disparities: Presenter (s): DaKysha Moore, NCAT, United States 2023. 109: pp. 25–26.

Lam CK, Schubert CF, Herron EK. Evidence-based practice competence in nursing students preparing to transition to practice. Worldviews Evid Based Nurs. 2020;17(6):418–26.

Lake MA. What we know so far: COVID-19 current clinical knowledge and research. Clin Med (Lond). 2020;20(2):124–7.

Shustack L. Integrating Google Earth in Community Health nursing courses: preparing globally aware nurses. Nurse Educ. 2020;45(2):E11–2.

Zeleníková R, et al. Self-assessed competence of final-year nursing students. Nurs Open. 2023;10(7):4607–18.

Hyun A, Tower M, Turner C. Exploration of the expected and achieved competency levels of new graduate nurses. J Nurs Manag. 2020;28(6):1418–31.

Kukkonen P, et al. Nurse managers’ perceptions of the competence of newly graduated nurses: a scoping review. J Nurs Manag. 2020;28(1):4–16.

Nilsson J et al. Nurse professional competence (NPC) assessed among newly graduated nurses in higher educational institutions in Europe. 2019. 39(3): p. 159–67.

Kajander-Unkuri S et al. Students’ Self-assessed Competence Levels during Nursing Education Continuum - A Cross-sectional Survey. Int J Nurs Educ Scholarsh, 2020. 17(1).

Salminen L, et al. The competence of nurse educators and graduating nurse students. Nurse Educ Today. 2021;98:104769.

Numminen O, et al. Newly graduated nurses’ competence and individual and organizational factors: a multivariate analysis. J Nurs Scholarsh. 2015;47(5):446–57.

Södersved Källestedt ML, et al. Perceptions of managers regarding prerequisites for the development of professional competence of newly graduated nurses: a qualitative study. J Clin Nurs. 2020;29(23–24):4784–94.

Ezzati E, et al. Exploring the social accountability challenges of nursing education system in Iran. BMC Nurs. 2023;22(1):7.

Farsi Z, et al. Comparison of Iran’s nursing education with developed and developing countries: a review on descriptive-comparative studies. BMC Nurs. 2022;21(1):105.

Salem OA et al. Competency based nursing curriculum: establishing the standards for nursing competencies in higher education. 2018. 5(11): p. 1–8.

Noohi E, Ghorbani-Gharani L. and A.J.S.i.D.o.M.E. Abbaszadeh, A comparative study of the curriculum of undergraduate nursing education in Iran and selected renowned universities in the world 2015. 12(3): pp. 450–471.

Rassouli M, Zagheri Tafreshi M. J.J.o.c.e. Esmaeil. Challenges Clin Nurs Educ Iran Strategies. 2014;2(1):11–22.

Riazi S, et al. Understanding gaps and needs in the undergratue nursing curriculum in Iran: a prelude to design a competency-based curriculum model %J payesh (Health Monitor). Journal. 2020;19(2):145–58.

ADIB HM, Mazhariazad F. Nursing Bachelor’s Education program in Iran and UCLA: A comparative study 2019.

Farokhzadian J, et al. Using a model to design, implement, and evaluate a training program for improving cultural competence among undergraduate nursing students: a mixed methods study. BMC Nurs. 2022;21(1):85.

Sargazi O, et al. Improving the professional competency of psychiatric nurses: results of a stress inoculation training program. Psychiatry Res. 2018;270:682–7.

Faraji A, et al. Evaluation of clinical competence and its related factors among ICU nurses in Kermanshah-Iran: a cross-sectional study. Int J Nurs Sci. 2019;6(4):421–5.

Atashzadeh-Shoorideh F, et al. Essential dimensions of professional competency examination in Iran from academic and clinical nurses’ perspective: a mixed-method study. J Educ Health Promot. 2021;10:414.

Purabdollah M, et al. Comparison of the Iranian and scandinavian bachelor of nursing curriculum (Sweden): a scoping review. J Educ Health Promotion. 2023;12(1):389.

Benner P. J.B.o.s., technology and society, using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education . 2004. 24(3): p. 188–99.

World Health Organization. Nurse educator core competencies. Geneva, Switzerland: World Health Organization. 2016 [cited 23 June 2023; https://www.who.int/hrh/nursing_midwifery/nurse_educator050416.pdf .

Purabdollah M, et al. Competencies expected of undergraduate nursing students: a scoping review. Nurs Open. 2023;10(12):7487–508.

Bondy KN. Clinical evaluation of student performance: the effects of criteria on accuracy and reliability. Res Nurs Health. 1984;7(1):25–33.

NLf N. Outcomes for graduates of practical/vocational, diploma, associate degree, baccalaureate, master’s, practice doctorate, and research doctorate programs in nursing . New York 2010; 201]. https:api.semanticscholar.org/corpus ID: 68620057.

Aguayo-González M, Castelló-Badía M, Monereo-Font C. Critical incidents in nursing academics: discovering a new identity. Rev Bras Enferm. 2015;68(2):195–202. 219 – 27.

Scott Imus FJJNEP. Nurse anesthesia student’s personality characteristics and academic performance: A big five personality model perspective 2019. 9: pp. 47–55.

Neishabouri M, Ahmadi F, Kazemnejad A. Iranian nursing students’ perspectives on transition to professional identity: a qualitative study. Int Nurs Rev. 2017;64(3):428–36.

Zheng S, et al. New nurses’ experience during a two year transition period to clinical practice: a phenomenological study. Nurse Educ Today. 2023;121:105682.

Aryuwat P, et al. An integrative review of resilience among nursing students in the context of nursing education. Nurs Open. 2023;10(5):2793–818.

Ayaz-Alkaya S, Simones J. Nursing education stress and coping behaviors in Turkish and the United States nursing students: a descriptive study. Nurse Educ Pract. 2022;59:103292.

Akhtar-Danesh N, et al. Perceptions of professionalism among nursing faculty and nursing students. West J Nurs Res. 2013;35(2):248–71.

Keeling J, Templeman J. An exploratory study: student nurses’ perceptions of professionalism. Nurse Educ Pract. 2013;13(1):18–22.

Nilsson J, et al. Development and validation of a new tool measuring nurses self-reported professional competence–the nurse professional competence (NPC) scale. Nurse Educ Today. 2014;34(4):574–80.

Berkow S, et al. Assessing new graduate nurse performance. J Nurs Adm. 2008;38(11):468–74.

Lofmark A, Smide B, Wikblad K. Competence of newly-graduated nurses–a comparison of the perceptions of qualified nurses and students. J Adv Nurs. 2006;53(6):721–8.

Park E, Choi J. Attributes associated with person-centered care competence among undergraduate nursing students. Res Nurs Health. 2020;43(5):511–9.

Tong V, Epeneter BJ. A comparative study of newly licensed registered nurses’ stressors: 2003 and 2015. J Contin Educ Nurs. 2018;49(3):132–40.

Florin J, et al. Educational support for research utilization and capability beliefs regarding evidence-based practice skills: a national survey of senior nursing students. J Adv Nurs. 2012;68(4):888–97.

Reid J, et al. Enhancing utility and understanding of evidence based practice through undergraduate nurse education. BMC Nurs. 2017;16:58.

Phillips JM, Cullen D. Improving the adoption of evidence-based practice through RN-to-BSN education. J Contin Educ Nurs. 2014;45(10):467–72.

Stievano A, Tschudin V. The ICN code of ethics for nurses: a time for revision. Int Nurs Rev. 2019;66(2):154–6.

Ministry of Education and Research. Norwegian qualifications framework: levels and learning outcome descriptors… 2011 [cited 23 June 2023; https://www.regjeringen.no/contentassets/e579f913fa1d45c2bf2219afc726670b/nkr.pdf .

Chen Q, et al. Differences in evidence-based nursing practice competencies of clinical and academic nurses in China and opportunities for complementary collaborations: a cross‐sectional study. J Clin Nurs. 2023;32(13–14):3695–706.

Missen K, McKenna L, Beauchamp A. Registered nurses’ perceptions of new nursing graduates’ clinical competence: a systematic integrative review. Nurs Health Sci. 2016;18(2):143–53.

Leonardsen AL, et al. Nurses’ perspectives on technical skill requirements in primary and tertiary healthcare services. Nurs Open. 2020;7(5):1424–30.

Duchscher JE. B.J.J.o.a.n. Transition Shock: Initial Stage role Adaptation New Graduated Registered Nurses. 2009;65(5):1103–13.

Ajemba MN, Ikwe C, Iroanya JC. Effectiveness of simulation-based training in medical education: assessing the impact of simulation-based training on clinical skills acquisition and retention: a systematic review. World J Adv Res Reviews. 2024;21(1):1833–43.

Krystallidou D et al. Interprofessional education for healthcare professionals. A BEME realist review of what works, why, for whom and in what circumstances in undergraduate health sciences education: BEME Guide No. 83 Medical Teacher, 2024: pp. 1–18.

Sun Y, et al. Critical thinking abilities among newly graduated nurses: a cross-sectional survey study in China. Nurs Open. 2023;10(3):1383–92.

Download references

Acknowledgements

The authors extend their gratitude to all the nursing students and faculties who took part in this study.

This article is part of research approved with the financial support of the deputy of research and technology of Tabriz University of Medical Sciences.

Author information

Authors and affiliations.

Department of Nursing, Khoy University of Medical Sciences, Khoy, Iran

Majid Purabdollah

Medical Education Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran

Majid Purabdollah, Vahid Zamanzadeh, Akram Ghahramanian, Leila Valizadeh, Saeid Mousavi & Mostafa Ghasempour

Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Vahid Zamanzadeh

Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran

Akram Ghahramanian & Mostafa Ghasempour

Department of Pediatric Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Leila Valizadeh

Department of Epidemiology and Biostatistics, Assistant Professor of Biostatistics, School of Health, Tabriz University of Medical Sciences, Tabriz, Iran

Saeid Mousavi

You can also search for this author in PubMed   Google Scholar

Contributions

M P: conceptualized the study, data collection, analysis and interpretation, drafting of manuscript; V Z: conceptualized the study, analysis and interpretation, drafting of manuscript; LV: conceptualized the study, data collection and analysis, manuscript revision; A Gh: conceptualized the study, data collection, analysis, and drafting of manuscript; S M: conceptualized the study, analysis, and drafting of manuscript; M Gh: data collection, analysis, and interpretation, drafting of manuscript; All authors read and approved the final manuscript.

Ethics declarations

Ethics approval and consent to participate.

All the participants voluntarily participated in this study and provided written informed consent. The study was approved by the ethics committee of the Tabriz University of Medical Sciences (Ethical Code: IR.TBZMED.REC.1400.791) and all methods were performed in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Purabdollah, M., Zamanzadeh, V., Ghahramanian, A. et al. Competency gap among graduating nursing students: what they have achieved and what is expected of them. BMC Med Educ 24 , 546 (2024). https://doi.org/10.1186/s12909-024-05532-w

Download citation

Received : 23 November 2023

Accepted : 07 May 2024

Published : 16 May 2024

DOI : https://doi.org/10.1186/s12909-024-05532-w

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Nursing education
• Self-Assessment
• Nursing students
• Professional Competency Professional

BMC Medical Education

ISSN: 1472-6920

• Submission enquiries: [email protected]
• General enquiries: [email protected]

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• GMS J Med Educ
• v.36(6); 2019

Language: English | German

Clinical reasoning – an approach for decision-making in education and training for biomedical scientists

Clinical reasoning als konzept der klinischen entscheidungsfindung in aus- und weiterbildung in der biomedizinischen analytik, angelika homberg.

1 Universitätsklinikum Heidelberg, Abteilung Allgemeinmedizin und Versorgungsforschung, Heidelberg, Germany

Heidi Oberhauser

2 fh gesundheit, Bachelor/Master Biomedizinische Analytik, Innsbruck, Austria

Sylvia Kaap-Fröhlich

3 Careum Stiftung, Bereich Bildungsentwicklung, Zürich, Switzerland

Aim: Explicitly addressing clinical reasoning (CR) is seen as a promising opportunity in the teaching of the biomedical sciences to enable students to acquire the skills to meet the challenges posed by ever more complex health care processes. The quality of diagnostic decisions plays an essential role here. Our aim is to examine if biomedical scientists recognize the practical relevance of CR and are able to apply it as a reflective framework for their professional practice.

Method: In two different educational settings, biomedical science students were asked to look closely at CR in the context of the degree program and to indentify the different forms of reasoning used in their internships and professional practice. The written descriptions were analyzed for content and discussed in the seminars.

Results: In both scenarios, the analyses of the students’ descriptions and discussions showed that examining the different forms of CR helped to raise conscious awareness of thought and decision-making processes, encouraging students to think critically about them and to articulate insights about them, as well as recognize the importance of different reasoning strategies when making specific medical decisions.

Conclusion: CR for biomedical scientists could help make decision-making processes visible for other occupational groups and thus advantageously integrate specific professional expertise into health care.

Over the long term, an interdisciplinary focus on CR could foster and promote the development of a shared discourse and interprofessional collaboration.

Zusammenfassung

Zielsetzung: Die explizite Auseinandersetzung mit Clinical Reasoning (CR) wird in der Ausbildung der Gesundheits- und Medizinalberufe als vielversprechende Möglichkeit gesehen, um für die Herausforderungen komplexer werdender Gesundheitsversorgungsprozesse zu qualifizieren. Die Qualität diagnostischer Entscheidungen spielt dabei eine elementare Rolle. Ziel dieses Projektes ist, zu überprüfen, ob Medizinisch-technische Laborassistenten/Biomedizinische Analytiker (MTLA/BMA) die praktische Relevanz des CR erkennen und als Reflexionsrahmen für ihr berufliches Handeln nutzen können.

Methodik: In zwei unterschiedlichen Bildungsszenarien setzen sich MTLA/BMA in Anlehnung an das Lernfeldkonzept mit CR auseinander und identifizieren unterschiedliche Reasoningformen in ihrem Praktikumseinsatz/beruflichen Alltag. Die schriftlichen Aufzeichnungen wurden inhaltsanalytisch ausgewertet und in den Seminaren mündlich diskutiert.

Ergebnisse: Die Auswertungen der Aufzeichnungen und die Diskussionen der Studierenden zeigten in beiden Szenarien, dass die Auseinandersetzung mit den unterschiedlichen CR-Formen dazu beitrug, Denk- und Entscheidungsprozesse ins Bewusstsein zu rufen, kritisch zu hinterfragen und sprachlich zum Ausdruck zu bringen sowie die Bedeutung unterschiedlicher Reasoning-Strategien in konkreten beruflichen Entscheidungsprozessen zu erkennen.

Schlussfolgerung: CR für MTLA/BMA könnte dazu beitragen, Entscheidungswege für andere Berufsgruppen sichtbar zu machen und auf diese Weise das professionsspezifische Wissen in Patientenversorgungsprozesse gewinnbringend zu integrieren.

Langfristig könnte die berufsgruppenübergreifende Auseinandersetzung mit CR die Entwicklung eines gemeinsamen Sprachduktus und interprofessionelle Zusammenarbeit fördern.

1. Introduction

Since health care decisions are becoming increasingly complex, there is a need to develop professional frameworks [ 1 ], [ 2 ] and for coordinated interprofessional collaboration among medical teams [ 3 ]. Concepts describing the decision-making process, such as clinical reasoning (CR), can assist such processes because the particular patterns of reasoning are made visible [ 4 ], [ 5 ], [ 6 ]. There are many definitions of CR [ 7 ], [ 8 ]. Generally, what is meant are the complex thinking processes engaged in by health care professionals, to which expertise, cognition and meta-cognition, and hypothetico-deductive approaches are central. Different forms of reasoning are categorized [ 6 ] in the literature with emphasis on various aspects such as ethics, interaction and relevance to science [ 7 ], [ 9 ], [ 10 ].

In Germany, CR in medical education has been more implicitly taught, even though the explicit embedding of CR in the curriculum appears very promising [ 11 ], [ 12 ], [ 13 ]. In the therapeutic occupations, such as physiotherapy and occupational therapy, a more direct grappling with CR has had a long tradition and has been anchored in the curriculum in many ways [ 7 ], [ 14 ], [ 15 ], [ 16 ], [ 17 ]. Forms of CR are described in the practice of laboratory diagnostics which, in addition to technical and scientific aspects, emphasize the logic of clinical and patient-centered decision-making [ 4 ], [ 18 ]. These are hardly covered in the education of biomedical scientists, although these occupations assume an elementary role in the process of providing health care. They are responsible for generating valid findings to serve as the basis for subsequent clinical decisions. In regard to diagnostic processes, it has been noted that the interactive use of reasoning concepts can reduce errors [ 19 ], [ 20 ] and encourage the integration of internal evidence in the decision-making process [ 21 ]. Oberhauser outlines in a theoretical fashion how individual forms of reasoning can be applied to the practice of the biomedical sciences [ 22 ].

2. Project description and method

The model of CR according to Higgs & Jones is covered in detail with students in two selected educational settings at different universities and involving different degree programs (see table 1 (Tab. 1) ). The corresponding seminars specifically address scientific, conditional, interactive, narrative, pragmatic and ethical reasoning. The aim of these seminars is to foster and encourage critical examination of the students’ own decisions and their development of professional patterns of reasoning by applying theory to reflect on practical decisions.

To investigate the transferability of the CR concept to biomedical science, assignments were given based on the degree program [ 23 ] to elicit application of theoretical knowledge to real work situations.

Ten students enrolled in the bachelor degree program in Interprofessional Healthcare at the University of Heidelberg’s School of Medicine [ 24 ], [ 25 ] were asked to describe concrete examples of the pre-analytical, analytical and post-analytical work processes for the forms of reasoning listed above and to justify each decision that was made based on what knowledge was applied.

Independently of this, 37 students in the master degree program in Biomedical Sciences at the Health University of Applied Sciences ( fh gesundheit ) in Innsbruck and Berlin reflected on their practical work experiences in which forms of reasoning were used and differentiated between those they were most familiar with and those that needed to be worked on and refined. In both of the degree programs these questions were processed in writing and then discussed as a group. The written texts were analyzed for content [ 26 ] (see table 2 (Tab. 2) ).

The undergraduate students studying biomedical sciences in Heidelberg were able to find concrete examples of all seven forms of reasoning in the stages of pre-analysis, analysis, and post-analysis. In addition to professional expertise acquired through education, the students specifically identified the workplace’s Standard Operating Procedures (SOP), their own experiences, and the sharing of information among colleagues as comprising the body of knowledge on which their reasoning was based. In respect to ethical reasoning, the students also identified their own discretion as playing a role. Students did not feel themselves to be sufficiently qualified to engage in interactive or ethical reasoning.

The graduate students in Innsbruck and Berlin were also able to recognize all of the forms of reasoning within the analytical biomedical processes of their work. The most familiar forms of reasoning for them were scientific, interactive and pragmatic reasoning (see table 3 (Tab. 3) ). It is striking that, in contrast to the undergraduate students, the graduate students reported that conditional, narrative and ethical reasoning were also among the most familiar forms to them. The practical relevance of CR was acknowledged in both degree programs, and the students were successful in applying the theoretical concept to their professional practice and in reflecting upon their own decision-making processes. Due to their professional experience, the graduate students provided considerably more complex descriptions of concrete work situations than the undergraduates, as was expected. Ethical and narrative reasoning in the context of the biomedical sciences was cited in both educational settings as needing further refinement.

4. Discussion

For the participating students, the seminars were able to help raise awareness of thought and decision-making processes, encouraging the students to critically examine and articulate them in words. The students in both learning environments felt themselves to be most familiar with scientific reasoning. The students studying at the masters level possessed more professional experience and in part held leadership positions, which could explain why they felt better able to use conditional, narrative and ethical reasoning and felt better qualified to engage in interactive reasoning than the undergraduate students. Systematic reasoning for those first beginning professional practice can lead to a lack of reflection on patterns of reasoning and can mean that reasoning processes are not adapted to specific situations [ 27 ]. CR enables a complex understanding of cases and encourages diagnostic performance during education if, along with systematic practice, other perspectives are integrated into specific decision-making processes [ 12 ], [ 13 ], [ 19 ], [ 28 ], [ 29 ]. Woods describes that for diagnostic decisions which are made with increasing professional experience, the knowledge gained from that experience along with intuition are increasingly drawn upon, while basic knowledge is pushed into the background. Diagnostic errors can also happen in these cases where there is no consistent inclusion of standard knowledge in the decision-making process [ 30 ], [ 31 ]. Focus can be placed specifically on the possibility of errors when teaching CR at more advanced levels of education [ 32 ], [ 33 ]. The differentiated development and fostering of the forms of reasoning during all educational phases, including further education could contribute to balancing and successfully synthesizing different sources of knowledge and decision-making processes.

5. Conclusion

Addressing CR helps biomedical scientists to understand the complexity of professional practice, to recognize the corresponding need for professionalism and formal qualifications, and to critically analyze one’s own decision-making processes. CR for biomedical scientists can contribute to making the decision-making process visible to other occupational groups and thus integrate professional expertise advantageously into the provision of health care.

Over the long term, an interdisciplinary focus on CR could foster and promote the development of a shared discourse. Consistent, longitudinal anchoring of appropriate learning content into the undergraduate and graduate curricula of all medical and health care professions would be necessary. As such, CR represents a very promising practical model for interprofessional education.

Competing interests

The authors declare that they have no competing interests.

School of Nursing

• Which Program is Right for Me Overview
• Comparing the PhD & DNP
• Technical Standards
• Bachelor of Science in Nursing
• Master of Nursing
• PhD in Nursing
• Doctor of Nursing Practice
• Certificate Overview
• Adult Gerontological Acute Care Nurse Practitioner Certificate
• Leadership in Health Information Technology for Health Professionals Certificate
• Population Health Informatics and Technology (PHIT) Certificate
• Post-Graduate Certificate Program Overview
• Meet Our Students
• Current Student Resources
• Office of Student & Career Advancement Services
• Research Overview
• Research Projects
• Research Day
• Faculty Grants
• Faculty Experts
• Laboratory of Clinical Exercise Physiology
• Publications Overview
• Books by Faculty
• Research Seminars
• Student Research Resources
• About the Office of Nursing Research and Scholarship
• News & Events Overview
• Minnesota Nursing Magazine Overview
• Current Issue
• Magazine Issue Archive
• Clinical Preceptors Overview
• BSN/MN (Prelicensure) Preceptor Information
• DNP Preceptor Information
• Clinical Preceptor e-Toolkit
• Nurse-midwifery specialty
• DNP Project Ideas
• Nurse Practitioners Clinic
• School of Nursing at a Glance
• School of Nursing Leadership
• Our Faculty
• Faculty Emeriti & Faculty Ad Honorem
• Cooperatives
• Faculty Honors and Awards
• Employment Opportunities
• Our Facilities Overview
• Bentson Health Communities Innovation Center
• Bakken Center for Spirituality and Healing
• Global Health Overview
• Visiting Scholars
• Global Collaborations
• Global Health Faculty Scholars
• Opportunities for Students
• Inclusivity, Diversity & Equity
• Professional Development
• Giving to Nursing Overview
• Areas of Need
• Scholarships
• Impact Stories
• Ways to Give
• Board of Trustees
• History Overview
• Heritage Committee
• History of Our School Leadership
• Program Histories
• Historical Videos and Photos
• Sigma Theta Tau International Overview
• Zeta Chapter Board
• Grants & Awards
• Volunteer Opportunities
• Alumni Overview
• Submit a Class Note
• Alumni Society Awards Overview
• Rising Star Award
• Distinguished Alumni Humanitarian Award
• Excellence in Practice Award
• Board of Directors
• Degree Verification
• Volunteering
• Centers Overview
• Center for Adolescent Nursing Overview
• Center Projects
• Learning Opportunities
• Publications
• Center for Aging Science & Care Innovation Overview
• Center for Child and Family Health Promotion Research Overview
• Center for Children with Special Health Care Needs Overview
• Contact form
• Center projects
• Center for Nursing Informatics Overview
• 2024 Nursing Knowledge: Big Data Science Conference
• Previous Conferences
• Nursing Knowledge Big Data Science Initiative
• Center for Planetary Health and Environmental Justice Overview
• Katharine J. Densford International Center for Nursing Leadership Overview
• Leadership Model
• Directorate
• Initiatives
• Contact the Center
• 2024 Planting Seeds of Innovation Colloquium

Leveraging generative AI to modernize nursing education

May 13, 2024 Brett Stursa

Martin Michalowski

The proliferation of new generative artificial intelligence (AI) tools can be challenging for nurse educators and clinicians to keep up with, as the potential benefits also come with new challenges.

Associate Professor Martin Michalowski, PhD, FAMIA, examines generative AI in nursing education and provides recommendations for nurse educators to optimize its use in recent publications.

Michalowski’s most recent article, The ChatGPT Effect: Nursing Education and Generative Artificial Intelligence, published in the February issue of the Journal of Nursing Education, examines generative AI in nursing education more broadly and urges nurse educators to harness its potential. 

Prompt engineering when using generative AI in nursing education, published in the January issue of Nurse Education in Practice, makes recommendations to integrate prompt engineering — the process of refining questions to get better results — in nursing education.

“Generative AI is one of the key required competencies and it needs to be integrated into the education nurses receive both as concepts to understand and as tools to use,” says Michalowski. “Similar to concepts in machine learning, natural language processing, automated reasoning, and other AI subfields, generative AI is transforming the provision of care. Therefore, it is important that nurses understand how to use it, and how its use impacts health care systems, providers and patients.”

Currently, he says that the most effective uses of generative AI in nursing classrooms is creating mock patient-related data and providing patient scenarios for practice.

“When applying learned theories or tools where patient-related data is needed, generative AI models are very useful for building synthetic data in different formats, like tables, free text notes, etc.,” says Michalowski.

“Additionally, generative AI enables critical thinking through the creation of patient use cases/scenarios. This application is one of the few where hallucinations — presenting output patterns as fact while they are clinically or factually incorrect — is acceptable. Students need to apply what they learned and use critical thinking to identify inaccuracies and contradictions in the use case. The instructor can also tailor the output use cases by providing important context for the learning exercise.”

Michalowski says it’s imperative nurse educators integrate AI competencies into their classrooms to ensure students are well equipped as future clinicians.

“Nurses have an incredible opportunity to lead health care’s transformation of clinical care with AI. They touch all aspects of the care process, understand the clinical problems and interface with patients. They are positioned to be the bridge between AI developers, health care practitioners and stakeholders,” says Michalowski. “However, to fully realize this potential they need basic AI competencies that aren’t currently part of their education.”

Categories: Research

In this Issue: Spring-Summer 2024

Sexual assault victim survivors and their communities have new tool to assist in seeking care

Collaboration of Re LAB, U-Spatial and MNCASA creates new map of Minnesota resources

• Admission Requirements
• Required Courses
• Admissions Requirements
• How to Apply
• Post-Graduate Certificate Program Plans by Specialty
• Message from the Dean
• Board of Visitors
• Adult & Gerontological Health
• Child & Family Health
• Population Health & Systems
• Tenured Faculty Opportunities
• Tenure-Track Faculty
• Clinical Track Faculty Opportunities
• Postdoctoral Fellowship Program
• Guidance for Applicants for faculty positions
• Marie Manthey Endowed Professorship
• Leaving a Nursing Legacy
• 100 Distinguished Nursing Alumni (A-E)
• 100 Distinguished Nursing Alumni (F-J)
• 100 Distinguished Nursing Alumni (K-O)
• 100 Distinguished Nursing Alumni (P-T)
• 100 Distinguished Nursing Alumni (U-Z)
• Distinguished Faculty Alumni
• Program Histories Overview
• Adult-Gero Nurse Practitioner Programs
• DNP Program
• Geriatric Nurse Practitioner/Geriatric Clinical Nurse Specialist
• Health Innovation and Leadership
• Integrative Health and Healing
• Master of Nursing Administration
• Nurse Anesthesia
• Nurse Midwifery
• Nursing Informatics
• Pediatric Primary Care Nurse Practitioner
• PhD Program
• Practical Nursing Program
• Pre-licensure programs
• Psychiatric-Mental Health
• Public Health Nursing
• Women's Health Nurse Practitioner
• Evidence-based Practice Grants
• Research Grants
• Travel Grants
• Summer Institute in Adolescent Health
• Past Summer Institutes in Adolescent Health
• Clinical Teaching in Nursing Homes
• Resources for Clinical Teaching in Nursing Homes
• Competencies for Public Health Nursing Practice Instrument
• Families as Teachers
• Doctoral Education Pathway for American Indian/Alaska Native Nurses
• Accreditation
• Call for Abstracts
• Registration
• Online Teaching Resources
• 2022 Nursing Knowledge: Big Data Science Conference
• 2020 Nursing Knowledge: Big Data Science Conference
• 2019 Workgroups
• 2018 Workgroups
• 2017 Nursing Knowledge: Big Data Science Conference
• 2016 Workgroups
• 2015 Workgroups
• 2014 Nursing Knowlege: Big Data Science Conference
• 2013 Nursing Knowledge: Pre-conference Materials
• Vision and Mission
• Five-Year Strategic Plan
• Steering committee
• Resources for Workgroup Members
• Nursing Knowledge: Big Data Science Conference
• Nursing Big Data Repository
• Contact information and social media
• Foresight Leadership

Mapping Critical Thinking, Clinical Reasoning, and Clinical Judgment Across the Curriculum

Affiliation.

• 1 Associate Clinical Professor (Dr Noll and Ms Jones), Associate Dean for Academic Affairs and Associate Professor (Dr Hunt), and Director of Simulation (Ms Jones), Auburn University College of Nursing, Auburn, Alabama.
• PMID: 37000918
• DOI: 10.1097/NNE.0000000000001413

Background: Critical thinking, clinical reasoning, and clinical judgment are skills nurses use when caring for clients. However, teaching and evaluation of clinical judgment are challenging for faculty.

Problem: Before revising a curriculum, it is necessary to map current practices and determine a framework for revisions.

Approach: Faculty mapped critical thinking, clinical reasoning, and clinical judgment activities across the 5-semester traditional baccalaureate program. Use of an external consultant helped faculty to determine additional activities that could be used to assess clinical judgment in classroom and clinical settings. Faculty worked together to develop teaching strategies and Next Generation National Council Licensure Examination (NCLEX) item types for assessing clinical judgment.

Conclusion: Using the National Council of State Boards of Nursing Clinical Judgment Model as an educational framework can guide faculty in curriculum mapping, revisions, and development of clinical judgment activities and assessment.

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

• Clinical Competence
• Education, Nursing, Baccalaureate*
• Nursing Education Research
• Students, Nursing*