Safe and effective clinical judgment is a quality sought in new graduate bachelor of science in nursing (BSN) registered nurses (RN) because this skill improves patient safety and outcomes. Clinical judgment has long been identified as essential for the professional practice of the RN [1, 2, 3, 4]. In recent years, nursing education has been the focus of increasingly onerous legislation, as well as political and nursing organization initiatives, to ensure baccalaureate of science in nursing (BSN) students are afforded a learning experience that will prepare new graduates to enter the workforce as competent professionals (5, 6, 3). As a direct impact of the National Academy of Science, Engineering, and Medicine, formally the Institute of Medicine (IOM) , report and supported by the American Association of College of Nursing (AACN)  and the Accreditation Commission for Education in Nursing [ACEN], formerly the National League for Nursing Accrediting Commission , nursing programs are held responsible for preparing graduate BSNs with the competency to provide evidence-based practice that supports positive patient outcomes.
The AACN  outlined that nursing programs must support the development of graduate BSN nurses in the areas of critical thinking, communication, assessment, and technical skills. However newly license nurses lack competence in their judgment and ability to make sound clinical decisions [8, 9, 10). Evidence has shown the development of competency in clinical judgment is interrelated with the time allocation and opportunities offered in the experiential clinical learning experience [11, 12]. In 2010, the Tri-Council of Nursing, an alliance among the American Association of Colleges of Nursing (AACN), National League for Nursing (NLN), American Organization of Nurse Executives, and American Nurses Association, in a joint collaboration with the Robert Wood Johnson Foundation, threw their collective support behind the Future of Nursing: Campaign for Action program. This program promotes established outcomes and academic progression plans to increase the preparedness of the BSN nursing workforce at state, school, and national levels [5, 3].
Nursing faculty are expected to find ways to innovate and adapt academic programs so that the programs maintain academic rigor and relevance to a rapidly changing health care industry [13, 14]. Academia is challenged with finding ways to develop critical judgment skills to support the nursing process, furthering the students’ application, analysis, and synthesis of nursing science [12, 15]. Twenty-first-century leaders in nursing education are drawing their attention to the learning opportunities that support professional competency of nursing students, which in turn have nursing researchers investigating how we can further strenghten the foundation of the clinical learning experience and practice settings. The purpose of this study was to add to the body of knowledge related to an evolving model of BSN clinical practice setting.
Transition to Professional Practice
Bridging the gap of nursing science theory to professional practice remains a challenge for nursing programs. For the graduate BSN, practice readiness is defined as having the knowledge foundation of a generic RN who can execute job-specific skills necessary to provide safe, effective, and quality nursing care . Epstein and Hundert  described competency as the accustomed mannerisms of communication, psychomotor skills, professional composure, ethics, and reflections that steer the nurse’s professional practice for the benefit of the individual and community. Newly licensed RNs must assume a role change to become independent practicing professionals [18, 19]. The graduate BSN must possess complex thinking skills, draw inferences on information gathered within the realm of patient care, and utilize knowledge and skills learned in academia to formulate a course of action .
A review of literature reveals an expectation of academia to educate nursing students to enter the workforce ready to work independently, within a short orientation period [21, 22, 23]. Underpinning the graduate BSN’s successful transition into practice, Romyn et al.  reported the need for new nurses entering the practice setting to “hit the ground running” (p. 8). Kinghorn et al.  and Romyn et al.  observed that health care employers expect new graduates to transition to practice quickly, although new graduate BSNs’ transitions are hindered by chronic understaffing, insufficient orientation time, increasingly complex patient care assignments, and negative nursing work culture. The 2013–2015 NLN strategic plan (as cited in ) underscored the importance of cultivating a future nursing workforce that supports an interdisciplinary team approach to provide patient-centered care to advance the nation health. Murray et al.  found that only 10% of hospital leaders, compared to 90% of nursing faculty, had confidence in new graduate BSNs’ ability to deliver safe and organized care. The discrepancy lies in how these two groups—hospital leaders and nursing faculty—define practice readiness .
Rush et al.  estimated the cost to recruit, hire, orient, precept, and train a new nurse was $40,000 per new graduate BSN. While the turnover rate of newly licensed nurses in their first year of practice ranges from 35% to 60% . The financial impact and retention challenges have brought academia and service leadership together to re-evaluate the theory-to-practice gap documented throughout the nursing research literature. Confounding this problem, 46% of experienced practice nurses in hospital settings are over the age of 50 . In turn, health care organizations are justifiably worried about how to sustain the professional RN workforce needed to care for the acuity of patients.
In 2000, the National Council of State Board of Nursing (as cited in ) sought to develop a transition to practice model for newly licensed nurses. The aim for this model was for health care organizations to develop a structured preceptor orientation model that would support the transition to professional role of a newly licensed graduate nurse . These programs have demonstrated reductions in the 12-month turnover rate of newly graduated BSNs from 7.1% to 4.3% over a span of 10 years . Despite improvements in retaining newly graduated BSNs in practice, health care organizations remained challenged with the financial burden of both retaining and training newly licensed nurses .
Nursing education leaders are faced with the challenge of preparing BSN graduate nurses to have the foundation of professional practice necessary to enter into practice [1, 2]. New graduate BSNs enter the profession as novices on the novice-to-expert spectrum . They draw upon formally learned nursing science and personal learning experiences as a basis for their professional practice, referred to as situated learning. A nursing program must support individual student development of problem-solving skills, critical thinking, prioritization, professional ethics, communication, and evidence-based nursing care [31, 32]. As new graduate BSNs gain experience, they are better able to abstract and pay finite attention to the priorities of care. The guidance, support, and feedback provided in the clinical learning environment (CLE) enhances the supportive environment, allowing students to develop their professional competency and clinical judgment . Benner , in reporting on the Carnegie study, concluded that the traditional pedagogy in nursing education does not foster application or demonstration of knowledge to actual clinical bedside nursing. It is an expectation that nursing students, through their experiential clinical learning, will gain insight in clinical judgment skills; however, not all students have equal opportunities . The Carnegie study, published in the Educating Nurses: A Call for Radical Transformation, supports student socialization into the professional role as the best learning practice . Awareness of the positive impact of CLE compels the question of how do we—academia, nurse educators in the clinical learning setting, and leadership—facilitate the transition of the BSN student with safe clinical judgment into professional practice.
Clinical Learning Environment
The clinical learning environment (CLE) is a critical component of nursing education [34, 35, 36]. Although student-centered learning has long been advocated in research, nursing curricula have been slow to embrace this philosophy and to address the needs of diverse learner styles . Faculty have traditionally utilized the clinical setting to assess students’ ability to demonstrate synthesis of didactic material through their individual clinical decision making . The CLE allows students to develop individual critical thinking skills, clinical reasoning skills, enhanced communication skills, prioritization skills, and organization abilities . The CLE provides the construct for students to conceptualize the social, behavioral, and psychomotor skills, as well as knowledge of nursing. The development of these competencies is interrelated with the time allocation and opportunities offered in the experiential clinical learning experience [11, 12].
In an active clinical learning environment, students need to have access to and interaction with a spectrum of patients . In a traditional CLE faculty assign a student to one or two patients per clinical experience. Faculty must organize, plan, and ensure that each student is given equal opportunity to achieve learning objectives. In this traditional clinical model, students have limited opportunities to demonstrate, synthesize, or apply theory to their bedside nursing because the 8:1 faculty-to-student ratio precludes such luxuries . The faculty must decide between a faculty-centered versus a learner-centered teaching approach . Faculty allocation of time in clinical might not be sufficient to repeat psychomotor skills, deliver direct patient care, and meet all student learning needs. However, because the acuity of patients is steadily increasing, so is the need for closer supervision of students delivering direct nursing care [12, 2]. Facilitating skills and patient learning experiences has proven to be challenging . Experiences gained by individuals or groups of students are varied and go unplanned. Even with careful strategic planning, the CLE is subject to variability.
The Dedicated Education Unit [DEU] nursing clinical model is an academic service collaboration in which one hospital reserves one or more inpatient care units exclusively for the use by one nursing program. The DEU CLE creates a triad in which the student, expert staff RN (preceptor RN), and nursing faculty partnership enhance a progressive collaboration and education effectiveness in building the future competent graduate BSN workforce [41, 42, 43]. The DEU clinical model offers the student an experiential 1:1 learning environment, in which the RN preceptor shapes the professional practice of the BSN student by role-modeling professional skills, attitudes, and behavior, hence providing contexts for professional roles and clinical judgment in a clinical setting [18, 39]. The one-on-one instruction of the DEU model allows students to assume increased accountability for patient care [44, 20, 45]. Under the DEU model, RN preceptors can point out errors, how to anticipate errors, and initiate risk mitigation practices . Providing opportunity for nursing students to be immersed in the interdisciplinary health care team, which encourages bi-directional communication, mutual respect, and shared decision making to achieve quality patient care [47, 46]. This model for CLE appeals to millennial students’ learning preference of experiential learning, motivation for reinforcement, collaborative attitude, and work style [48, 49, 46, 50].
Academic Service Partnership
For school of nursing to remain sustainable, their leaders must have the vision to ensure the graduates of their programs have a sufficiently broad experience and skill set to meet the needs of health care employers. Academic programs and health care organizations have formed strategic alliances and academic service collaborations to utilize and create an innovative clinical learning setting: the DEU. Strategic alliances and academic service collaborations are innovative ways to address the predicted nursing shortage . Academic service collaborative agreements allow schools nursing programs and health care organizations to share resources, talented professionals, and financial resources in arrangements that can be mutually beneficial . Literature on these alliances has demonstrated (a) successful student transition into professional practice, as well as retention of students as future staff nurses; (b) changes in the role of staff RNs (clinical ladder, integration into the education area, and mentoring future staff); (c) expansion of educational learning capacities for schools of nursing; (d) commitment of healthcare organizations to retain future nursing staff, reduce orientation time, and offer opportunities for research; and (e) improved patient and staff satisification [41, 16, 53, 54].
The literature includes research on new BSN nurses’ transition into practice, perception of preparedness for their new professional role, and clinical learning experience [44, 18, 46, 10]. By sharing a vision and mutual respect, the service academic collaboration of a DEU clinical model in literature has enhanced student professional competency, led to the recruitment of new graduate nurses, facilitated transition into practice, and shortened the orientation period for new hires. Within the health care organization, the DEU has increased patient satisfaction, fostered career ladder advancement of staff RNs into administration and educational roles, fostered a positive changes in teamwork, and offered incentives for quality improvements and research [55, 41, 56, 57, 34, 58, 47].
In response to the IOM  report, the AACN  commissioned a comprehensive investigation to identify areas in which these academic service collaborations could strengthen the influence and sustainability of schools of nursing. Highlights of the AACN report revealed (a) academic nursing is not aligned to be an equal partner in the administration of health care, (b) academic service alliances are not cultivated to the fullest capacity, and (c) funding of initiatives for program expansion is not readily available. Collaboration of academia with hospital organizations has mutual benefits [47, 16, 53]. This alliance has been found to enhance clinical learning cultures, promote the generation of research, improve evidence-based patient care delivery, and allow for career development of the preceptor RN [47, 16]. Under the DEU model, students and patients become the beneficiaries of heightened professional, educational, and clinical practices . The nursing unit benefits from enhanced teamwork, satisfaction, professionalism, productivity, evidence-based practice changes, and emerging patient care improvements .
Sound clinical judgment is a competency expected of newly graduated BSN RNs entering professional practice . Schools of nursing are under pressure to respond to the nationwide call from professional nursing organizations and the health care industry for newly graduated BSN RNs who are professionally competent to care for multiple complex patients [12, 7]. There is a need to re-evaluate the clinical learning experience offered to students in a generic BSN program [60, 3]. The experiential CLE offers students opportunities to develop their clinical judgment, role socialization, and professional practice . The purpose of this study was to evaluate the CLE of the DEU as compared to the traditional faculty-led CLE in terms of the influence of these methods on individual student development of clinical judgment psychometric skills. The intent of this project was to evaluate individual students’ ability to demonstrate safe and effective patient care in pre- and post-observation (simulation scenario). In this study, the hypothesis—Does the clinical learning setting influence the ability of the individual student demonstration of safe and effective nursing care (clinical judgement competency)—was tested using a pre- and post-simulation experience.