൩ng students participating in high-fidelity simulation” · tanner’s cjm is the theoretical...

$: ൩ng students participating in high-fidelity simulation” · Tanner’s CJM is the theoretical model that guided this study. Tanner \⠀㈀㘀尩 developed a clinical judgment$
Michelle Bussard, PhD, RN, ACNS-BC, CNE

Presenter

Presentation Notes

I am going to present my dissertation titled “Interpretive description of clinical judgment within reflective journals of nursing students participating in high-fidelity simulation”

Objectives The learner will identify an effective teaching/learning

strategy to assist pre-licensure nursing students to develop clinical judgment skills

The learner will identify how reflective journals can be used to assist in developing clinical judgment

The learner will identify the nature of clinical judgment as revealed in reflective journals

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Problem Statement

Lack of clinical experiences

Graduating nurses have a lack of clinical judgment

Graduates are expected to enter workforce with clinical judgment

Presenter

Presentation Notes

The problem statement for this study was that graduating nurses lack clinical judgment decision-making abilities. Employers of new graduates, expect new graduates to enter the workforce with developed clinical judgment. However, nursing students must have experience to gain clinical judgment, and because of a lack of clinical experiences and clinical sites, many students will not have enough clinical experiences to gain clinical judgment.

Purpose Statement

To identify an effective teaching/learning strategy for pre-licensure nursing students to develop clinical judgment skills prior to graduation.

Presenter

Presentation Notes

The purpose of this study is to identify an effective teaching/learning strategy for pre-licensure nursing students to develop clinical judgment skills prior to graduation. Understanding the nature of clinical judgment development within reflective journals after students participate in progressive HFS scenarios may provide nurse educators with a viable teaching/learning strategy for pre-licensure nursing students.

Significance of Study

Theory practice

gap

Clinical judgment

Optimal patient

care

Patient outcomes

Patient safety

Presenter

Presentation Notes

The significance of this study is that the reflective journaling in combination with HFS, clinical experiences, and classroom activities will help decrease the theory-practice gap. Narrowing the theory-practice gap that is often times identified by nursing students can be decreased by an effective teaching/learning strategy such as reflective journaling after HFS scenarios. By decreasing the theory-practice gap, students will be able to develop clinical judgments, which ultimately will help the student deliver optimal patient care, improve patient outcomes and improve patient safety. Benner et al (2010) stated that educators need to incorporate active teaching strategies within a curriculum to foster clinical judgments.

Research Question What is the nature of clinical judgment development as revealed in student reflective journals after participating in four progressive HFS scenarios?

Relevant Research

Reprinted with permission

Presenter

Presentation Notes

Tanner’s CJM is the theoretical model that guided this study. Tanner (2006) developed a clinical judgment model to assist nurses, nurse educators, and nursing students to better understand how clinical judgment decisions are made. Tanner (2006) describes the Clinical Judgment Model as containing four concepts: noticing, interpreting, responding, and reflecting (see Figure 1). Noticing is the nurse’s initial grasp of a situation, expectations of a patient situation, knowledge of the patient’s normal patterns, knowledge of similar or previous patient situations, and knowledge from a textbook. In the interpretation phase of the model, the nurse is using the data from noticing to formulate meaning (Tanner, 2006). Responding occurs next when the meaning of the data is used to determine appropriate nursing interventions to care for the patient. Reflection is the last phase of the model and most important aspect of developing clinical judgment.

Relevant Research Continued

LASATER CLINICAL JUDGEMENT RUBRIC

Dimension Exemplary Accomplished Developing Beginning Effective noticing involves: Focused observation Focuses observation appropriately; regularly observes

and monitors a wide variety of objective and subjective data to uncover any useful information

Regularly observes and monitors a variety of data, including both subjective and objective; most useful information is noticed; may miss the most subtle signs

Attempts to monitor a variety of subjective and objective data but is overwhelmed by the array of data; focuses on the most obvious data, missing some important information

Confused by the clinical situation and the amount and kind of data; observation is not organized and important data are missed, and/or assessment errors are made.

Recognizing deviations from expected patterns

Recognizes subtle patterns and deviations from expected patterns in data and uses these to guide the assessment

Recognizes most obvious patterns and deviations in data and uses these to continually assess

Identifies obvious patterns and deviations, missing some important information; unsure how to continue the assessment

Focuses on one thing at a time and misses most patterns and deviations from expectations; misses opportunities to refine the assessment

Information seeking Assertively seeks information to plan intervention; carefully collects useful subjective data from observing and interacting with the patient and family

Actively seeks subjective information about the patient’s situation from the patient and family to support planning interventions; occasionally does not pursue important leads

Makes limited efforts to seek additional information from the patient and family; often seems not to know what information to seek and/or pursues unrelated information

Is ineffective in seeking information; relies mostly on objective data; has difficulty interacting with the patient and family and fails to collect important subjective date

Effective interpreting involves: Prioritizing data Focuses on the most relevant and important data

useful for explaining the patient’s condition Generally focuses on the most important data and seeks further relevant information but also may try to attend to less pertinent data

Makes an effort to prioritize data and focus on the most important, but also attends to less relevant or useful data

Has difficulty focusing and appears not to know which data are most important to the diagnosis; attempts to attend to all available data

Making sense of data Even when facing complex, conflicting, or confusing data, is able to (a) note and make sense of patterns in the patient’s data, (b) compare these with known patterns (from the nursing knowledge base, research, personal experience, and intuition), and (c) develop plans for interventions that can be justified in terms of their likelihood of success

In most situations, interprets the patient’s data patterns and compares with known patterns to develop an intervention plan and accompanying rationale; the exceptions are rare or in complicated cases where it is appropriate to seek the guidance of a specialist or a more experienced nurse

In simple, common, or familiar situations, is able to compare the patient’s data patterns with those known and to develop or explain intervention plans; has difficulty, however, with even moderately difficult data or situations that are within the expectations of students; inappropriately requires advice or assistance

Even in simple common, or familiar situations, has difficulty interpreting or making sense of data; has trouble distinguishing among competing explanations and appropriate interventions, requiring assistance both in diagnosing the problem and developing an intervention

Effective responding involves: Calm, confident manner Assumes responsibility; delegates team assignments;

assesses patients and reassures them and their families Generally displays leadership and confidence and is able to control or calm most situations; may show stress in particularly difficult or complex situations

Is tentative in the leader role; reassures patients and families in routine and relatively simple situations, but becomes stressed and disorganized easily

Except in simple and routine situations, is stressed and disorganized, lacks control, makes patients and families anxious or less able to cooperate

Clear communication Communicates effectively; explains interventions; calms and reassures patients and families; directs and involves team members, explaining and giving directions; checks for understanding

Generally communicates well; explains carefully to patients; gives clear directions to team; could be more effective in establishing rapport

Shows some communication ability (e.g., giving directions); communication with patients, families, and team members is only partly successful; displays caring but not competence

Has difficulty communicating; explanations are confusing; directions are unclear or contradictory; patients and families are made confused or anxious and are not reassured

Well-planned intervention/flexibility Interventions are tailored for the individual patient; monitors patient progress closely and is able to adjust treatment as indicated by patient response

Develops interventions on the basis of relevant patient data; monitors progress regularly but does not expect to have to change treatments

Develops interventions on the basis of the most obvious data; monitors progress but is unable to make adjustments as indicated by the patient’s response

Focuses on developing a single intervention, addressing a likely solution, but it may be vague, confusing and/or incomplete; some monitoring may occur

Being skillful Shows mastery of necessary nursing skills Displays proficiency in the use of most nursing skills; could improve speed or accuracy

Is hesitant or ineffective in using nursing skills Is unable to select and/or perform nursing skills

Effective reflecting involves: Evaluation/self-analysis Independently evaluates and analyzes personal clinical

performance, noting decision points, elaborating alternatives, and accurately evaluating choices against alternatives

Evaluates and analyzes personal clinical performance with minimal prompting primarily about major events or decisions; key decision points are identified, and alternatives are considered

Even when prompted, briefly verbalizes the most obvious evaluations; has difficulty imagining alternative choices; is self-protective in evaluating personal choices

Even prompted evaluations are brief, cursory, and not used to improve performance; justifies personal decisions and choices without evaluating them

Commitment to improvement Demonstrates commitment to ongoing improvement; reflects on and critically evaluates nursing experiences; accurately identifies strengths and weaknesses and develops specific plans to eliminate weaknesses

Demonstrates a desire to improve nursing performance; reflects on and evaluates experiences; identifies strengths and weaknesses; could be more systematic in evaluating weaknesses

Demonstrates awareness of the need for ongoing improvement and makes some effort to learn from experience and improve performance but tends to state the obvious and needs external evaluation

Appears uninterested in improving performance or is unable to do so; rarely reflects; is uncritical of himself or herself or overly critical (given level of development); is unable to see flaws or need for improvement.


Presenter

Presentation Notes

Lasater created a clinical judgment rubric based off of Tanner’s model to evaluate a students development of clinical judgment after participating in HFS scenarios. The rubric has 11 dimensions that a student is evaluated against. With each dimension evaluated as beginning, developing, accomplished, or exemplary. The rubric has effective noticing, effective interpreting, effective responding, and effective reflecting.

Relevant Research Continued Reflective thinking, reflective

journaling, debriefing

Presenter

Presentation Notes

Reflective thinking is the most important aspect to the development of clinical judgment. Nursing regulatory boards include reflection as a mandatory competency of every practicing nurse and consider reflective thinking to be an essential skill for continued professional growth. Two types of reflection include reflection-in-action and reflection-on-action, which assist in the development of clinical judgment. Reflection-in-action is the act of concurrently evaluating an experience, whereas, reflection-on-action is the act of evaluating an experience after it is completed. Nurse educators need to include various reflective activities to assist nursing students in developing clinical judgment decision-making skills. Strong evidence suggests that reflective activities should include guided questions to create in-depth dialogue. Reflective Journaling is a learning activity that nursing students use to close the theory-practice gap. After a clinical experience, nursing students complete a reflective journal to develop metacognitive frameworks and become self-aware. Additionally, reflective journals are a means to assist nursing students in developing meaningful connections that can be used in future patient situations. Nursing students who participate in reflective journaling activities need guided questions to effectively reflect upon the clinical situation and develop appropriate clinical judgments for future practice situations. Debriefing after a HFS scenario is considered a reflective strategy that nurse educators can incorporate to assist students in developing clinical judgments and bridge the theory-practice gap. Debriefing is completed immediately following a HFS scenario and is done verbally in a small group with a facilitator and should have focused reflective questions. Debriefing can include video assistance, journaling, or wikis as an additional benefit of the reflective period.

Relevant Research Continued High -Fidelity Simulation


Presenter

Presentation Notes

HFS increases student self-confidence, clinical judgment, critical thinking, and effective debriefing. Students who participate in HFS scenarios have an improvement in self-confidence when caring for a. The student is able to build self-confidence in his or her clinical skills and abilities during the HFS scenario, which can then assist the student in developing clinical judgments. NLN/Jeffries Framework is used to guide, design, implement, and evaluate simulation scenarios.

Methodology

Qualitative Interpretive Description

Specific to Nursing

Clinical Phenomena

Rigorous Credible

Transfer-able

Presenter

Presentation Notes

The interpretive description design utilized in this study is a design developed by Sally Thorne, a nurse researcher, and is a unique qualitative methodology specific for nursing where a clinical phenomenon with a theoretical base is researched to identify new and innovative methods of incorporating the phenomenon into nursing practice. Interpretive description is an approach that not only describes data but also interprets and explains the data analytically so new knowledge and evidence can emerge about the clinical phenomenon and can be immediately used to improve the science of nursing. The qualitative interpretive description approach is an established research method that originated from the tradition of social science with a design plan to create linkages in clinical data and form new practice ideas. The interpretive description methodology utilized in this study was designed to specifically answer clinical questions that do not fit into traditional qualitative methods such as phenomenology, grounded theory, or ethnography, which are based in disciplines other than nursing. Nursing research and nursing theory cannot always be answered using qualitative methodologies developed from philosophical, sociological, or cultural traditions. These qualitative methods that have been traditionally used to answer clinical nursing questions did not provide depth, interpretation, had a limited scope, were not holistic, or provide information that was relational to the practice of nursing. Therefore, to expand nursing science and theory, a nursing qualitative interpretive description approach was developed that has integrity, rigor, is credible, legitimate, and has a foundation in the philosophy of nursing practice. The philosophical and epistemological foundation that interpretive description is grounded in “adhere[s] to the systematic reasoning of [the nursing] discipline and yield[s] legitimate knowledge for” the practice of nursing. This design is important to the nursing profession because data that is collected can be immediately applied to clinical situations without the support of quantitative randomized control studies. The rigor of the design supports clinical phenomenon that may directly impact patient care and nursing practice. For this study, reflective journals were analyzed using Thorne et al.’s (1997) qualitative approach of interpretive description. This qualitative methodology was appropriate for this study because a nursing clinical question with a theoretical foundation was researched. The clinical question of the nature of clinical judgment development was specifically researched using the theoretical lens of Tanner’s Clinical Judgment model and LCJR. The clinical phenomenon of clinical judgment within associated reflective journaling after HFS scenarios may directly impact nursing practice and therefore patient safety and patient outcomes. An in-depth analysis of the phenomenon of clinical judgment within associated reflective journaling after HFS scenarios was needed to advance the science of nursing education and therefore the practice of nursing.

Methodology Continued

• Reflective Journals

• Inductive analysis of clinical judgment

• Medical Surgical nursing course

• All eligible students

• Clinical Judgment Model

• LCJR

Theoretical Scaffolding

Sample Selection

Data Source

Analytic Data

Analysis

Presenter

Presentation Notes

Theoretical scaffolding. In theoretical scaffolding, the researcher is using previous theoretical knowledge, quantitative evidence, or clinical experience to guide the interpretive description study. The use of previous knowledge will assist in the development of new and innovative knowledge that can be applied to the nursing profession. Scholars in the field of nursing education believe that reflective activities after HFS is an area of research that may advance the science of nursing education. Sample selection. Sample selection in interpretive description studies is guided by the theoretical underpinnings of the study and must be large enough so that the researcher can confidently claim that the results of the study are not biased and may be transferable to other subjects or persons. A sample size of five to 30 is an average sample size in interpretive description study, but may go as high as 200 study participants. Determining what size the sample should be is based on how many subjects the researcher believes will provide enough data for the findings to have merit. For this study, the medical surgical nursing course at FRMC School of Nursing was chosen because it used HFS four times in a semester with progressing complexity of each scenario. No other nursing course at FRMC School of Nursing used HFS in this manner. To answer the research question for this study, students needed to participate in progressive HFS scenarios followed by reflective journaling to identify the nature of clinical judgment development.. For this study, the sample size was estimated from the number of typical enrolled students in the medical surgical nursing course. The intended audience was medical surgical nursing students and nurse educators in a pre-licensure nursing program with a projected sample size of 30-38 nursing students. The average enrollment for the junior medical surgical nursing course at FRMC School of Nursing is 32. The projected sample size of 30-38 students for this study was representative of the typical medical surgical class at FRMC where data was collected. Data sources. Data sources that are typical in qualitative research include interviews, focus groups, observation, case reports, retrospective review of charts, and journaling. The type of data source used must be in conjunction with the theoretical framework, as well as the sample selection so that new information can be learned about the clinical phenomenon. For this study, the primary data source was a retrospective review of reflective journals completed by junior diploma nursing students who participated in four progressive HFS scenarios during a medical surgical nursing course. The themes of clinical judgment were explored, described, and interpreted using the narrative content of the reflective journals as the primary data source. The reflective journals had guided questions, with terminology specific to Tanner’s model. The guided questions assisted students in a focused discussion rather than the student “feeling lost” and unable to describe the simulation scenario. Analytical data analysis. In analytic data analysis, the researcher inductively analyzes the data to conceptualize, theorize, and synthesize the data to form a new meaning or new knowledge that can be innovatively applied to the clinical phenomenon. For analytic data analysis, the analysis is both iterative and inductive. The researcher alternates between a theoretical lens and emerging themes to conceptualize, theorize, and synthesize meaning that can be innovatively applied to the clinical phenomenon.

Population and Data Collection • Junior pre-licensure • Medical surgical Diploma

• 4 Scenarios – simple to complex • IRB approval • Criteria

Inclusion

• Informed consent • Unique coding • Simulation facilitator

Data collection

• Member check group • Nurse educators

Rigor and Confirmability

Presenter

Presentation Notes

The sample for this study included 30 junior diploma pre-licensure nursing students at one school of nursing in Northeast Ohio. The students had completed a medical surgical nursing course that utilized progressive HFS scenarios, oral debriefing, video recordings, and reflective journaling. The students participated in four HFS scenarios. The scenarios starts as simple and increased in complexity as the students knowledge and skill level increased. Theoretical content was delivered in the classroom first and then the students participated in the HFS scenarios. The scenarios followed the NJSF for design, implementation, and evaluation. After IRB approval was obtained and permission to use premises was obtained, I obtained informed consent from the students. All students met inclusion criteria for this study which are: (a) all students must have participated in four progressive HFS scenarios during Nursing Care of Adults I (NCA I; a medical surgical nursing course), (b) orally debriefed after each HFS scenario, (c) viewed a video recording of each HFS scenario, (d) completed a reflective journal after each HFS scenario, (e) successfully passed NCA I, and (f) provided written informed consent. Additionally, all students must be greater than 18 years of age and may withdraw from the study at any time. Student progress in the curriculum was not affected by participating or not participating in this study. The simulation facilitator uniquely coded each reflective journal so to prevent bias during data analysis. A member check focus group was conducted after data analysis of the reflective journals to provide rigor to the study. Thorne recommends completing a member check focus group to share overall data findings with study participants to gain additional insights and clarification of data. A total of 12 study participant attended the member check focus group. Informed consent was obtained for the member check focus group and inclusion criteria was (a) all students must have participated in four progressive HFS scenarios during Nursing Care of Adults I (NCA I; a medical surgical nursing course), (b) orally debriefed after each HFS scenario, (c) viewed a video recording of each HFS scenario, (d) completed a reflective journal after each HFS scenario, (e) successfully passed NCA I, (f) provided consent to have Michelle view the reflective journal, and (g) provided written informed consent. For confirmability of results, two nurse educators were asked to evaluate the themes and data analysis. Inclusion criteria for the nurse educators include: nursing education experience, experience as a nurse, experience with HFS, experience using Tanner’s clinical judgment model and LCJR.

Sample Population for Reflective Journals

Sample size 30

Presenter

Presentation Notes

This is a graphic of the demographics of the reflective journal study participants. A total of 27 female, 3 males, 27 Caucasian and 2 Asian (1 chose not to answer race). 15 had prior health care experience before entering nursing school ranging 4 months to 7 years and 15 did not have experience.

Sample Population for Member Check Group

Sample size 12

Presenter

Presentation Notes

This is the demographic information of member check focus group study participants. Ten females, two males, ten Caucasian, two Asians. Eight had no health care experience prior to nursing school and 4 did ranging from 4 months to 2 ½ years

Sample of Nurse Educators

Presenter

Presentation Notes

Nurse educator #1: 33 years experience in nursing, 22 years experience as nurse educator, MSN, MeD, and CNE. Nurse educator #2: 11 years experience in nursing, 3 years experience as nurse educator, MSN Both with experience in HFS, Tanner’s model and LCJR.

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Analysis of Reflective Journals Theme 1

Theme 2

Theme 3

Theme 4

• Expectations about the patient

• Recognition of a focused assessment

• Interpretation of medications, laboratory data, and diagnostics

• Communication with the patient

Presenter

Presentation Notes

Each of the journals were read in their entirety prior to beginning coding. After each journal was read through, they were uploaded into QSR NVivo10. Codes and themes were created using NVivo10. Queries were generated using commonly used words. After themes were created, journal entries were then linked to each of the themes in NVivo10. The eight themes that emerged from the reflective journal include the above 8 themes. Explain each of the themes with a description of each of them from journal one to journal four.

Analysis of Reflective Journals Continued Theme 5

Theme 6

Theme 7

Theme 8

• Collaboration and interprofessionalism

• Prioritizing interventions

• Skillfulness with interventions

• Incorporation of skills and information into real patient situations

Findings Interpretation through Tanner’s Clinical Judgment Model

Noticing

Expectations about the patient

Recognition of a focused

assessment

873 comments in journals

Interpreting

Interpretation of medications,

laboratory data, and diagnostics


Responding

Communicating with the patient

Collaboration and

interprofession-alism

Prioritizing interventions


Reflecting

Skillfulness with interventions

Incorporation of skills and

information into real patient situations


Presenter

Presentation Notes

Using Tanner’s Clinical Judgment as a theoretical lens of data analysis, I was able to place each of the themes into the concepts of clinical judgment. Theme 1 & 2 fall under noticing, theme 3 falls under interpreting, theme 4,5,6 falls under responding, and themes 7 & 8 falls under reflecting. The number of total comments for each of the concepts are also listed in this figure.

Findings Interpretation through Lasater Clinical Judgment Rubric

Presenter

Presentation Notes

After the data was analyzed and themes emerged, the data was then evaluated using LCJR to determine the level of clinical judgment development a student obtained within reflective journals after participating in HFS scenarios. Conclusions from the data analysis indicated that students were mostly in the beginning to developing of clinical judgment within journal one and mostly in accomplished to exemplary by journal four. This concludes that a students development of clinical judgment can be evaluated within reflective journals using the LCJR. There were over 170 comments coded as beginning or developing in journal one and only 52 comments coded as beginning or developing in journal four. Whereas there were only 65 comments coded as accomplished/exemplary in journal one and 170 comments coded as accomplished/exemplary in journal 4.

Nature of Clinical Judgment Development

Bussard (2013)

Presenter

Presentation Notes

This is a model to depict the nature of clinical judgment development within reflective journals. Explain the model – this is an image that illuminates the theoretical model of Tanner’s Clinical Judgment along with LCJR.

Recommendations for Nurse Educators

Presenter

Presentation Notes

Nurse educators can use the reflective journals to identify if a student is able to meet course objectives. The educator can view the students thinking in the journals to identify patient outcomes and patient safety concerns. The educator then can provide feedback to the student to help him or her gain additional clinical judgments. For example, if the student made a medication error in the simulation scenario, the outcome and safety associated with that medication error can be discussed in the journal through reflection and faculty feedback. An educator can tailor a students clinical experiences towards the reflective journal experiences and thinking. For example, if the student recognizes that he or she is weak in IV skills, the educator can ensure that the student receives a patient required IV therapy during clinical. The reflective journals can be used throughout a curriculum rather than in just one nursing course. Each course that uses HFS can use reflective journaling. This type of journaling can then help identify if a student meets the curriculum learning outcomes. The reflective journaling is very rich in data and can be a greater source of understanding a students overall measure of clinical judgment at the end of the curriculum as compared to a multiple choice examination. The reflective journals will provide educators an insight into the students thinking and progress in the whole curriculum.

Conclusion

Teaching/learning strategy

Journal one to journal four

Findings parallel Tanner and Lasater

Connects literature of HFS, debriefing, and reflective journaling

Nature of Clinical Judgment

Development

Presenter

Presentation Notes

In conclusion, findings of this study are that the reflective journals are an effective teaching/learning strategy that can be used after progressive HFS scenario in pre-licensure nursing programs to assist in the development of clinical judgment. The development of clinical judgment was evident from journal one to journal four in which students had many beginning and developing comments in journal one and many more accomplished and exemplary comments in journal four. The findings of this study parallel those of Tanner’s clinical judgment model and LCJR. Students were able to notice, interpret, respond and reflect within the reflective journals. LCJR was also found to be an effective tool to evaluate a students development of clinical judgment in reflective journals. The results of this study connect the current literature on HFS, debriefing, and reflective journaling. HFS and debriefing have significant evidence indicating that they both improve a students confidence and clinical judgments. Reflective journaling after clinical experiences also has evidence that indicates it improves clinical judgments. This study connects HFS, debriefing, and reflective journaling in the development of clinical judgment.

References Lasater, K. (2007). Clinical judgment development: Using

simulation to create an assessment rubric. Journal of Nursing Education, 46(11), 496-503. Retrieved from www.slackjournals.com/jne

Lasater, K. & Nielsen, A. (2009). Reflective journaling for clinical judgment development and evaluation. Journal of Nursing Education, 48(1), 40-44. Retrieved from www.slackjournals.com/jne

Mariani, B., Cantrell, M. A., Meakim, C., Prieto, P., & Dreifuerst, K. T. (2013). Structured debriefing and students’ clinical judgment abilities in simulation. Clinical Simulation in Nursing, 9(5), e147-e155. doi: 10.1016/j.ecns.2011.11.009

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Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. Retrieved from www.slackjournals.com/jne

Thomas, C. M., Bertram, E., & Allen, R. (2012). Preparing for transition to professional practice: Creating a simulated blog and reflective journaling activity. Clinical Simulation in Nursing, 8(3), e87-e95. doi: 10.1016/j.ecns.2010.07.004

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൩ng students participating in high-fidelity simulation” · tanner’s cjm is the theoretical...

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