Teaching registered nurse (RN) prelicensure students to make decisions about nursing care is a long-standing goal of nursing education and key to nurses' delivery of safe patient care. Despite strategic action by nursing education to teach clinical reasoning and judgment and the development of academic-practice partnerships and nurse residency programs to foster practice readiness, competence in these critical skills has not improved (Bashford et al., 2012; del Bueno, 2005; Kavanagh & Sharpnack, 2021; Theisen & Sandau, 2013). Unfortunately, new graduate nurses are often involved in errors of judgment related to medications, falls, and delays in care (Saintsing et al., 2011). The current version of NCLEX(R)-RN is designed to measure whether graduates of RN prelicensure programs have the knowledge to make safe entry-to-practice-level decisions about patient care; it was not designed to measure the cognitive processes involved in clinical judgment (National Council of State Boards of Nursing [NCSBN], 2018).
The NCSBN responded to this ongoing patient safety crisis with a strategic plan to measure clinical judgment on the next iteration of NCLEX-RN, the Next Generation NCLEX (NGN). It will measure knowledge as it has in the past but will also measure clinical judgment (NCSBN, 2021). This effort has led to heightened urgency for nurse educators to promote the development of students' clinical judgment. Several decision-making paradigms inform a variety of conceptual models and strategies for teaching clinical judgment (Dickison et al., 2019). Although a myriad of teaching strategies supporting development of these critical skills has been described (Tyo & McCurry, 2019), it is unclear how many programs use a clinical judgment model to guide teaching and learning, what benefits of model use they recognize, or what teaching strategies programs currently use.
BACKGROUND
Evidence of how clinical reasoning and judgment develop has advanced in recent years, calling into question the efficacy of relying on the nursing process for developing these skills. The nursing process has served as a proxy decision-making model for several decades (Pesut & Herman, 1998), yet it offers only superficial understanding of the complex thinking in clinical decision-making (Huckabay, 2009).
Critical thinking, clinical reasoning, and clinical judgment are used by nurses to make clinical decisions. Critical thinking is the general process of logic used to interpret common, everyday information and make appropriate decisions. Clinical reasoning, defined as the discipline-specific reasoning process that encompasses the cognitive processes through which nurses combine multiple contextual and personal factors with experience and reflection-in-action to make patient care decisions (Jessee, 2018), must be effective to inform sound decisions. These decisions reflect the nurse's clinical judgment, which encompasses clinical reasoning, and is defined as "the interpretation or conclusion about a patient's needs, concerns, or health problems, and the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response" (Tanner, 2006, p. 204). Hence, this study used the term clinical judgment to describe the reasoning skills and judgment required to make nursing decisions.
The development of clinical judgment requires purposeful scaffolding of learning opportunities over time to develop skill competence from novice toward expertise (Benner, 2001). A clinical judgment educational model provides a common language and guide for alignment of program and course outcomes, assessments, and teaching and learning strategies. Furthermore, use of a comprehensive theoretical model to guide a specific combination of individual teaching and learning strategies into a cohesive curriculum may support educators' efforts to promote clinical reasoning and judgment over time (Jessee, 2018).
Several models describe clinical judgment in nursing and are used by nurse educators for teaching clinical judgment. The Tanner clinical judgment model is grounded in the intuitive-humanistic paradigm and accounts for the influence of contextual factors, the nurse's background, and the nurse's relationship with the patient (Tanner, 2006). The model outlines a process that encompasses key elements of background information: noticing, interpreting, responding, and reflecting. It depicts the process as iterative and informed by real-time factors in the caregiving situation.
The clinical reasoning cycle (Levett-Jones et al., 2010) also describes clinical reasoning as a context-bound ongoing process and identifies factors that contribute to accurate interpretation of the situation. It presents eight phases: look, collect, process, decide, plan, act, evaluate, and reflect. Cognitive-based models grounded in the information processing paradigm include the outcome-present state test reasoning model (Kuiper et al., 2009; Pesut & Herman, 1998) and the developing nurses' thinking model (Tesoro, 2012). Both models rely on cognitive processing, logic, and testing of hypotheses as the foundation for clinical decision-making.
Based on these models, many teaching-learning strategies have been developed to facilitate nursing students' development of clinical judgment (Cappelletti et al., 2014; Tyo & McCurry, 2019). Simulation (Cazzell & Anderson, 2016; Victor et al., 2017), case-based learning (Foo et al., 2017), and concept mapping (Alfayoumi, 2019; Kuiper et al., 2009) engage students in identifying salient data, recognizing relationships among concepts, and prioritizing problems and actions. Concept-based strategies facilitate pattern recognition and nuanced differences among similar situations that warrant variation in prioritization and action (Gonzalez, 2018; Jessee, 2019; Lasater & Nielsen, 2009; Nielsen, 2016). Expert role modeling of thinking in action enhances student understanding of expert nurse reasoning (Lasater et al., 2014). Clinical coaching (Jessee & Tanner, 2016), questioning, and think-aloud strategies facilitate assessment of learners' thinking, and strategic feedback to improve knowledge and thought processes that contribute to sound judgment about patient care (Nielsen et al., 2016). Reflection is broadly used to promote improvement in clinical judgment in future practice (Monagle et al., 2018; Razieh et al., 2018). Debriefing and prebriefing are also commonly used strategies that support the development of clinical judgment in simulation and other clinical experiences (Al Sabei & Lasater, 2016; Dreifuerst, 2012; National League for Nursing (NLN), 2015; Page-Cutrara & Turk, 2017).
The NCSBN (2019) recently introduced the clinical judgment measurement model (CJMM) to structure assessment of multiple components of clinical judgment on the NCLEX-RN and in nursing education (Dickison et al., 2019). The model incorporates aspects of the intuitive-humanistic and cognitive decision-making paradigms to inform development of effective approaches to measuring clinical judgment. The NCSBN will use the CJMM to measure clinical judgment and score NCLEX-RN candidate responses on the 2023 version of the NCLEX-RN exam, called the NGN. It was developed as an assessment model, rather than a teaching model (Dickison et al., 2020).
With the growing interest in teaching clinical judgment associated with the upcoming changes in NCLEX-RN testing, better understanding of how clinical judgment models and teaching strategies are currently used will inform the path forward as well as provide a helpful baseline for effectiveness in preparation for NCLEX-RN and improving practice readiness. Though a variety of models and strategies for teaching clinical judgment are available, the number of prelicensure programs that use a model and specific teaching-learning strategies to develop clinical judgment is unknown.
STUDY PURPOSE
The purpose of this study is to provide foundational evidence for how prelicensure nursing programs are using clinical judgment models and teaching strategies to promote students' clinical judgment development. Specifically, it was designed to address these aims: 1) Describe the percentage of prelicensure nursing programs using the terms clinical judgment or clinical reasoning in program or course outcomes. 2) Describe the percentage of prelicensure nursing programs using a clinical judgment model to inform their curricula. 3) Identify the primary clinical judgment models and how they are used to inform prelicensure nursing curricula. 4) Describe the influence of NGN exam on dean/program director adoption of a clinical judgment model and teaching strategies to teach clinical judgment. 5) Describe the relationship between the length of time a clinical judgment model has been in use and dean/program director beliefs about the model's influence on student outcomes. 6) Describe the types of teaching strategies used to promote student development of clinical judgment. 7) Explore dean/program director beliefs about how their use or nonuse of a clinical judgment model and teaching strategies to guide student development of these skills is influencing student outcomes.
This article reports the findings for Aims 1-5 and the part of Aim 7 related to clinical judgment models. Findings for Aim 6 and the parts of Aim 7 related to teaching strategies will be reported in a second article.
METHOD
Design and Setting
A cross-sectional survey design used multiple-choice, yes/no, and open-response items to examine US prelicensure RN programs' use of clinical judgment educational models. Eligible participants included the entire population of deans/program directors of US prelicensure nursing programs preparing candidates for the NCLEX-RN. Participants were contacted using the NCSBN list of RN education programs authorized to allow their graduates to take the NCLEX-RN examination (NCSBN, 2021). Subsequently, a list from the NLN provided additional contact information. The inclusion criterion was employment as a dean/program director (or designee) of a prelicensure RN program in the US. Exclusion criteria included deans/directors of LVN/PN education programs and international nurse education programs. The study posed minimal risk to participants and was approved as an exempt study by the Vanderbilt University Institutional Review Board.
Procedure
An introductory email was sent to all US deans/program directors or designees identified as meeting the inclusion criterion (n = 2,589). The email introduction described the study purpose, confidentiality measures, instructions for survey access, and the primary investigator's contact information. The survey was activated for all study participants one week following the introductory email and was accessible for four weeks. Reminder emails were sent four times at weekly intervals to nonresponding participants, restating the purpose of the study and the importance of participation. Data were collected using REDCap(R) (Research Electronic Data Capture) secure web application.
Data Analysis
Descriptive analysis identified the use of clinical judgment models and teaching strategies to promote students' clinical judgment development within approved prelicensure programs. Qualitative responses to open-ended survey items were categorized by respondents' reported use of a clinical judgment model, namely, 1) they currently use a clinical judgment model, 2) they do not use a clinical judgment model but intend to start, and 3) they do not use a clinical judgment model and do not intend to start. Those responses were then examined by the researchers to identify similarities and differences across and within the three categories.
The distribution of program types invited to participate in the study was as follows: baccalaureate (BSN), 41 percent; associate degree (ADN), 54 percent; diploma, 2 percent; MSN/DNP entry to practice, 3 percent; BSN entry to practice, 0.4 percent; other, 0.08 percent. The acceptable response size (n = 237) was calculated using the following variables: possible number of respondents (n = 2,589), response distribution of program types (BSN, ADN, diploma, MSN/DNP entry to practice, BSN entry to practice, other) within the population of nursing programs (60 percent), margin of error (0.5), and confidence interval (CI; 90 percent). The CI was set at 90 percent because of the seminal nature of the study and the reduced risk of making Type I or Type II errors. This approach allowed for the potential to gather more information that could focus public discourse on more defined lines of inquiry for future research.
RESULTS
Sample
There were 241 total responses. The proportion of responses from each program type was conducted to establish generalizability of the results to the population of RN prelicensure programs. No statistical differences were identified for the BSN (z = -0.76, p = .4990) and ADN (z = 0.0596, p = .9525) programs, indicating a representative sample of BSN and ADN programs in the population. Statistical differences were identified in MSN/DNP entry to practice (z = -5.04, p = .0000), diploma (z = -5.42, p = .0000), BSN entry to practice (z = -17.32, p = .0000), and other (z = -14.65, p = .0000), indicating the samples for these program types were proportionally different from the population and generalizability to the population was inappropriate. The intent of the study was to report data on all program types; however, generalizability could only be established for ADN and BSN programs, and results are reported for ADN and BSN programs only.
The final sample consisted of 234 respondents; 55 percent represented ADN programs (n = 129). Of the ADN programs, 91 were public (71 percent) and 34 (26 percent) were private institutions; four programs did not respond. Of the BSN programs (n = 105, 45 percent), 40 were public (38 percent) and 62 were private institutions (59 percent); three programs did not respond (see Table 1). Respondents represented 45 states; Alaska, Idaho, Minnesota, North Dakota, and Rhode Island were not represented. The sampling strategy did not provide for stratification of responses for individual geographic region or specific state analysis. The low response rate from some states, along with a higher response rates from Florida (n = 28) and Texas (n = 21), did not allow for generalizability to individual states.
Aim 1. Describe the percentage of prelicensure nursing programs using the terms clinical judgment or clinical reasoning in program or course outcomes.
Many respondents (65 percent, n = 153) reported using the terms clinical judgment or clinical reasoning in program or course outcomes. BSN programs demonstrated the highest proportion of use of the terms (70 percent, n = 74); ADN programs demonstrated the lowest use (59 percent, n = 76). There was no appreciable difference in use of the terms when comparing public and private institutions.
Aim 2. Describe the percentage of prelicensure nursing programs using a clinical judgment model to inform their curricula.
Only 27 percent of respondents (n = 64) reported use of a specific model to inform the curriculum; 71 percent (n = 167) indicated they did not currently use a model. There was no statistically significant difference in use of a model between program types, with just 29 percent of ADN programs (n = 37) and 26 percent of BSN programs (n = 27) currently using a model.
The highest proportion of model use to inform curricula was by private institutions (30 percent, n = 29), compared with 25 percent (n = 35) of public institutions. Fifty one percent of respondents (n = 120) indicated they intended to start using a model; 20 percent (n = 47) indicated they did not (Table 1). There was no statistically significant difference between ADN and BSN programs' intent to start using a model.
Aim 3. Identify the primary clinical judgment models and how they are used to inform prelicensure nursing curricula.
Participants were asked to indicate if they currently used a model and to indicate which one, if applicable. Of the 64 programs that used a model, 41 used the Tanner (2006) clinical judgment model (65 percent). Seven programs (11 percent) used the clinical reasoning cycle (Levett-Jones et al., 2010). The remaining programs reported the use of several other resources.
INFORM DESIGN AND IMPLEMENTATION OF TEACHING AND LEARNING STRATEGIES
The most frequent use of clinical judgment models was to inform design and implementation of teaching and learning strategies, including connection of concepts between classroom and clinical, simulation and debriefing, and reflections. One respondent indicated the model is "incorporated into each course as part of the learning outcomes, linked to our program outcome related to clinical judgment [and] as the foundation for clinical teaching and evaluation in the clinical setting." Three respondents described integration of the model through its introduction in a single course, followed by purposeful development of clinical judgment with activities based on students' lived experiences and application to nursing situations.
FACILITATION OF CLINICAL TEACHING AND EVALUATION
The second most frequent use of models was to facilitate clinical teaching and evaluation as a guide for both experienced and adjunct clinical instructors. One respondent indicated, "We map our clinical and simulation experiences to this model by ensuring students have deliberate practice opportunities to develop skills associated with noticing, interpreting, responding, and reflecting." Another indicated "the model and associated experiential mapping ensures we are outcomes focused and ensures we are 'thinking about thinking' in meaningful ways."
Several respondents noted their chosen model was primarily used for discussion in clinical conferences, completion of clinical paperwork, and standardized assessment of student clinical competency. One respondent stated, "the model is helpful for guiding and coaching students through specific clinical situations, case-based learning activities, or simulation scenarios using the process of noticing, interpreting, responding, and reflecting to support student development of clinical judgment."
Aim 4. Describe the influence of NGN exam on dean/program director adoption of a clinical judgment model and teaching strategies to teach clinical judgment.
Respondents were asked when they adopted a model. Fifty-seven respondents reported using a model for <1 year (n = 15), 1-3 years (n = 16), 4-5 years (n = 11), and 6 years or more (n = 15). The introduction of the NGN was somewhat or extremely important for programs deciding to adopt a model in the past three years. Of the 15 programs adopting a model within the last year, 93 percent (n = 14) reported the introduction of the NGN was somewhat or very important to their decision. The same was true for 12 of the 16 programs adopting a model in the last one to three years (75 percent). Introduction of the NGN was less important if model use began more than three years ago before news of the NGN was widely available.
Aim 5. Describe the relationship between the length of time a clinical judgment model has been in use and dean/program director beliefs about the model's influence on student outcomes.
Respondents who reported using a model for more than four years indicated the model's influence on student outcomes was positive and integral to preparedness for practice. One participant explained, "We think it is providing us with good program outcomes as it is forcing students to critically think, determine what factors could lead to poor patient outcomes, and help them develop a plan to intervene before the patient deteriorates."
The beliefs of those using a model for less than three years and adopting it because of the introduction of NGN were centered around improving clinical judgment and guiding teaching and learning. One participant explained that model use helps "better guide and develop their thinking, focusing on identifying a problem vs. concern and knowing when and how to respond." Another commented that "the model provides a step-by-step plan for faculty which makes it easier to identify an issue."
Aim 7. Explore dean/program director beliefs about how their use or nonuse of a clinical judgment model and teaching strategies to guide student development of these skills is influencing student outcomes.
The programs currently using a model (n = 65) and those intending to start (n = 120) believed strongly that use of a framework or model should be intentional to improve outcomes and teaching. Those not using and not intending to start using a model (n = 47) indicated the use of various teaching strategies in lieu of a model. Specific findings about use of teaching strategies will be described in a future article.
Of those using a model, 23 program (36 percent) described positive results after implementation. Two respondents noted improvement in student confidence, stating that "applying the framework in multiple ways builds students' confidence" and "students are more confident, and can explain their decisions for client care." Four respondents indicated that students' preparedness for practice improved after implementation of a clinical judgment framework. One identified receiving "excellent feedback from employers on growing competency of new graduates." Another noted that "our outcomes are getting better each year. Students feel they are prepared to go into the workforce after graduation." One respondent indicated using a model "has assisted us to improve evaluation of students' ability 'to think like a nurse' and remediate, when necessary, to meet student outcomes" and "setting clear benchmarks is paramount to student success." Others emphasized introduction of a common language, for example, "The Tanner Clinical Judgment Model has given our faculty a shared language and research-based model for describing how nurses think in varied and often complex clinical situations that require clinical judgment. The model also provides a way for faculty to identify and specify areas where students may be struggling." Several respondents using a model identified higher NCLEX-RN pass rates; others reported no change because of existing student achievement of learning outcomes and high NCLEX-RN pass rates. One respondent anecdotally indicated that use of a model to inform virtual clinical experiences during the COVID-19 pandemic focused teaching and learning strategies on thinking, resulting in better student understanding of nursing concepts and application on exams than students in the previous cohort.
Of those not using a model but intending to start, responses indicated that use of a model would improve outcomes. For example, one respondent stressed the potential consequence of not using a model: "By not being purposeful and using a model, we are decreasing our first-time pass rates and lending to the theory-practice gap." Another emphasized the importance of using a model: "We use various methodologies to teach clinical reasoning and judgment; however, without an iterative, formal framework, students sometimes don't connect the clinical reasoning dots." Finally, one respondent related the use of a model to NCLEX: "I believe the integration of the steps of CJ [Clinical Judgment] model are important for future graduate success on the national licensing exam."
Of those not using a model and not intending to start, comments indicated that use of teaching strategies and current practices were enough to teach clinical judgment. For example, one respondent indicated that the use of a structured simulation debriefing format was an acceptable substitute for a model: "Since we began using Debriefing for Meaningful Learning, our student outcomes are consistently improved. Our NCLEX scores are higher, out clinical assessments are much higher, our student's exam scores are higher in didactic course and our partners report transition to practice is much better." Another respondent not intending to start indicated: "We are waiting until the NGN starts to decide how to move forward."
DISCUSSION
Study results provide a baseline understanding of how clinical judgment models are used across the United States, the significance of NGN to programs' decisions to adopt a model, and an understanding of dean/program director beliefs about how using or not using a model influences student outcomes. Twenty-seven percent of respondents reported using a model, and 51 percent intended to start; 20 percent did not intend to start using a model. Tanner's clinical judgment model was the most used, followed by the clinical reasoning cycle. Respondents reported using models to inform design of teaching/learning strategies and facilitate clinical teaching and evaluation.
This study is the only one of its kind to comprehensively survey nursing programs about their practices of teaching clinical judgment. Respondents represented a broad range of program types and geographic locations in the United States. The researchers also were representative of different areas of the country. The timing for this study precedes the debut of the NGN, thereby laying the groundwork for future research, including intervention studies examining the effectiveness of strategies to promote clinical judgment, as well as the value of NGN to evaluate clinical judgment.
The primary limitation of this study was the challenge of data collection during a pandemic and the inaccuracies of mailing list contact information, both of which contributed to a low response rate. Despite obtaining program and contact lists from both the NCSBN and the NLN, many inaccuracies were identified. Searches of program websites yielded some accurate contact information, yet in some cases, even website information was incorrect. The current system of data sharing and collection is inadequate to promote needed national research and benchmarking (Monagle et al., 2022).
Many programs use the terms clinical judgment, clinical reasoning, or critical thinking in course or program outcomes. This demonstrates a common understanding of the importance of focusing curriculum design and implementation strategies on this key competency needed for safe nursing practice. To our knowledge, there has been no other inquiry into whether programs include these terms in their program outcomes, leaving a gap in the understanding of how program outcomes are defined.
Many programs indicated a focus on NCLEX success in terms of model use. Although educational quality has traditionally been, to some degree, measured by NCLEX-RN success in all programs, reliance on this criterion has not translated to sound clinical judgment in practice (Kavanagh & Sharpnack 2021). The current NCLEX-RN measures basic knowledge and safe choices for nursing action; it does not measure critical psychomotor or affective skill competency, or the complex cognitive processes involved in sound clinical judgment, and should not be the primary outcome measure of curricular effectiveness (Dickison et al., 2019).
Most programs either use a clinical judgment model or plan to integrate one into their curricula in the near future. Tanner's (2006) clinical judgment model was the most widely used model in this study. According to Manetti (2019), Tanner's model has clear language and definitions, making it desirable for nursing education. A strength of Tanner's model is an associated developmental rubric for guiding teaching and assessment of student development of clinical judgment (Lasater, 2007). Some nursing education publishers have embraced Tanner's model, including Assessment Technologies Institute (n.d.) and Elsevier Health Sciences in Concepts for Nursing Practice (Giddens, 2021). However, others such as Elsevier Health Sciences' Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (Ignatavicius et al., 2021) have moved away from Tanner's model in favor of the NCSBN's CJMM (NCSBN, 2019) as a guide for teaching clinical judgment despite its development as an assessment model rather than a teaching model (Dickinson et al., 2020). Educators must mindfully consider the intended uses of clinical judgment models and use them accordingly in their practices.
Designing curricular and educational interventions should be based on comprehensive theoretical frameworks for clinical judgment development and education to foster well-rounded clinical judgment competency. This enables new graduates to reason through both unfamiliar and familiar patient situations toward the best patient outcomes (Jessee, 2018). Assessing student achievement of competency in individual components of clinical judgment should be undertaken with instruments developed from sound research and evidence-based measurement models (Dickison et al., 2019; Lasater, 2007).
The finding that some programs do not use a model and do not intend to start is concerning. Recent evidence indicates that the clinical judgment of new graduates may be continuing to decline (Kavanagh & Sharpnack, 2021), making clear the need for critical exploration of how to best promote students' learning of this skill. Teaching the complex competencies of clinical reasoning and judgment should be structured to ensure that multiple required cognitive skills are taught, practiced, and measured (Caputi, 2020; Gonzalez et al., 2021). Use of a model to evaluate current practices and guide quality improvement of curricular content and teaching strategies could promote the development of competencies needed by today's new graduate nurses. Use of a shared language among educators and all levels of students to give practical meaning to an abstract concept, such as clinical judgment, is advantageous. Although it is impossible to determine from this study if one model is better than another, the information provides baseline data for future studies.
Because the NCSBN determined that clinical judgment would be included in future NCLEX testing (NCSBN, 2019), the incorporation of a model to inform nursing curricula appears to have been expedited. Although some programs have had a model integrated into their curricula for many years, most programs using a model acknowledged the impending changes to NCLEX-RN as an impetus to adopt a model. This finding further demonstrates that many programs may still be focused on NCLEX-RN as a measure of curricular effectiveness when, in fact, the focus should be on specific, measurable practice competencies (O'Lynn, 2017).
IMPLICATIONS FOR FUTURE RESEARCH
These findings provide a foundation for much needed intervention studies examining the effectiveness of strategies to promote clinical judgment, as well as the value of the NGN to evaluate clinical judgment. The limited adoption of a clinical judgment model to guide curricula demonstrates the need for further inquiry about clinical judgment, how it develops, and best practices for teaching and evaluating this critical skill. Further research on individual models may allow for analysis of the effectiveness of each, thereby providing data for programs to make decisions about which model to adopt. In addition, a logical next step, especially after implementation of NGN, would be to compare outcomes for programs using a model with those that do not use a model. Further research using the CJMM may provide educators with a practical method for determining competency in individual components of clinical judgment (Dickison et al., 2019). Understanding how programs use clinical judgment educational models and teaching strategies, specifically to develop clinical reasoning and judgment, informs next steps to determine how they influence outcomes, to know how those outcomes translate to actual practice competency in clinical judgment, and to make recommendations for best practice for teaching clinical judgment.
CONCLUSION
Understanding how clinical judgment models are being used by prelicensure RN programs across the United States provides foundational information for designing a national strategy to prepare practice-ready graduates. Current individual efforts of nursing education, nursing practice, and nursing regulation to promote safe practice while well-intentioned are failing to achieve widespread results in practice. Expectations for student competency must be explored, researched, and transformed into a single congruent expectation shared by education, regulation, and practice. Furthermore, our separate yet inextricably connected academic and practice roles in the transformation of students to practice-ready graduates must be clearly delineated. This will foster consistent teaching, measurement, and continued growth of essential practice-focused skill sets, including clinical reasoning and judgment, as students make the transition from education to practice. Only then will we achieve an accepted standard of competency for nursing education, regulation, and practice in which new graduate nurses are able to learn, transition to practice, and grow to become experts providing safe, person-centered nursing care based on sound clinical judgment.
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