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A sys ema ic e iew o me hods o assessing clinical easoning in
nu sing s uden s
Naii e Salmani1, Imane Baghe i 2*
1Na ional Agency o S a egic Resea ch in Medical Educa ion, Teh an, I an
2 Facul y o Nu sing and Midwi e y, Resea ch Cen e o Nu sing and Midwi e y Ca e, Non-communicable Diseases Resea ch
Ins i u e, Shahid Sadoughi Uni e si y o Medical Sciences, Yazd, I an
A icle in o Abs ac
In oduc ion
In any educa ional sys em, mo ing lea ne s om
memo iza ion o easoning (an inno a i e way o sol e
p oblems) is a undamen al issue [1]. Reasoning is a
hinking p ocess ha ans o ms an undesi able o
p oblema ic si ua ion in o a desi able one by p ocessing
he subjec ma e [2]. Clinical easoning is one o he
impo an and essen ial skills in nu sing educa ion and
p ac ice [3, 4]. Clinical easoning in nu sing is a
cogni i e p ocess ha nu ses use o collec , syn hesize,
and unde s and in o ma ion [3] and iden i y and
diagnose pa ien p oblems [5] o guide decisions abou
pa ien ca e [3]. In o he wo ds, clinical easoning is he
abili y o a nu se o look a a la ge olume o da a and
hen accu a ely iden i y and apply e ec i e nu sing
p ac ices o add ess he p oblems iden i ied du ing
pa ien ca e [6]. Clinical easoning is o g ea impo ance
o lea ning and de eloping nu sing ca e. The e ec i e
use o clinical easoning in complex ca e si ua ions is
cu en ly one o he heal hca e equi emen s o apid
A icle his o y:
Recei ed 7 Dec. 2024
Accep ed 21 Aug. 2025
Published 13 Jul. 2025
Salmani e al. J Med Edu De . 2025; 18(2): 129-143 Jou nal o Medical Educa ion De elopmen
Backg ound & Objec i e: Nu sing ins uc o s can play a c ucial ole in enhancing s uden s'
clinical easoning skills by e alua ing hem and o e ing imely, cons uc i e eedback.
The e o e, iden i ying e ec i e clinical easoning assessmen ools is i al o accomplishing
his objec i e. To his end, his s udy aimed o e iew he me hods o assessing clinical
easoning in nu sing s uden s.
Ma e ials & Me hods: This sys ema ic e iew was conduc ed in May 2024 using he keywo ds
"Clinical Reasoning" and "Nu sing S uden s." Eligible a icles published in bo h English and
Pe sian we e sys ema ically sea ched in a ious na ional and in e na ional online da abases,
including SID, Magi an, Scopus, Web o Science, PubMed, and P oQues .
Resul s: A o al o 2893 a icles we e e ie ed om he ini ial sea ch indings. A e emo ing
duplica es and i ele an a icles based on he inclusion c i e ia, a quali a i e assessmen was
conduc ed using he C i ical App aisal Skills P og amme (CASP), he Mixed Me hods
App aisal Tool (MMAT), and he Joanna B iggs Ins i u e (JBI) checklis s. Ul ima ely, 20
a icles on clinical easoning assessmen ools o nu sing s uden s we e e iewed. The indings
e ealed ha esea che s u ilize a ange o ools o assess clinical easoning, wi h he mos
common being he Nu ses Clinical Reasoning Scale (NCRS), Sc ip Conco dance Tes s (SCTs),
key ea u e es s, Ou come-P esen S a e Tes (OPT), ub ics, and he iple jump exe cise.
Howe e , he alidi y and eliabili y o he ools used and hei accep abili y and cos -
e ec i eness ha e no been assessed in he li e a u e.
Conclusion: The indings indica ed ha he NCRS is he mos commonly used assessmen ool.
The e o e, conduc ing psychome ic e alua ions o his ool in I an is ecommended.
Fu he mo e, longi udinal s udies a e needed o e alua e he impac o clinical easoning
assessmen ools on nu sing s uden s and explo e how hese ools can be e ec i ely in eg a ed
in o nu sing cu icula.
Keywo ds: nu sing s uden s, clinical easoning, sys ema ic e iew, clinical easoning ools,
nu sing educa ion
*Co esponding au ho :
Imane Baghe i, A sys ema ic e iew
o me hods o assessing clinical
easoning in nu sing s uden s.
Email: imane.baghe [email protected]
Re iew A icle
How o ci e his a icle:
Salmani N, Baghe i I. A sys ema ic
e iew o me hods o assessing
clinical easoning in nu sing
s uden s. J Med Edu De . 2025;
18(2): 129-143.
[ DOI: 10.61882/edcj.18.2.129 ] [ Downloaded om edujou nal.zums.ac.i on 2025-10-03 ]
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Salmani e al
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: Assessing clinical easoning in nu sing s uden s
130 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025
assessmen o ca e needs and p o ision o high-quali y
ca e [3, 4].
Clinical easoning helps nu ses make he mos accu a e
decisions in clinical se ings and p o ide pe son-
cen e ed, high-quali y, e ec i e, and sa e pa ien ca e [7-
10]. In o he wo ds, nu ses wi h adequa e clinical
easoning skills posi i ely impac pa ien ca e ou comes
[11]. Howe e , a li e a u e e iew sugges s nu ses o en
ha e limi ed clinical easoning skills and use a ious
cogni i e s a egies [12, 13]. The mos commonly used
skill was checking o accu acy and eliabili y. The
easoning p ocess o nu ses encompasses he phases o
assessmen , analysis, diagnosis,
planning/implemen a ion, and e alua ion [14].
Nu ses wi h inadequa e clinical easoning skills ind
decision-making complex, wi h hei abili y o iage
pa ien s showing accu acy a es anging om 22% o
89% [12, 13]. These nu ses o en canno ecognize
si ua ions whe e he pa ien 's condi ion de e io a es and
ails o sa e he pa ien [11]. Poo clinical easoning
skills can lead o poo diagnosis, ailu e o p o ide
e ec i e ea men , inapp op ia e managemen , and
ad e se pa ien ou comes [15]. In o he wo ds, he
occu ence o hospi al complica ions in pa ien s is
di ec ly ela ed o he quali y o ca e and he clinical
easoning skills o ca egi e s [16]. The e o e,
de eloping clinical easoning skills be o e nu ses en e
he clinical ield is necessa y [7, 8].
S eng hening clinical easoning o nu sing s uden s is a
goal o nu sing educa ion [5] and is conside ed an
impo an opic in nu sing p og ams and lea ning
ou comes [13]. Nu sing ins uc o s a e esponsible o
assessing s uden s' unde s anding o he logic o clinical
ac ions, and one o he p ima y goals o clinical nu sing
educa o s is o de elop clinical easoning skills in
s uden s and b idge he gap be ween heo e ical and
p ac ical educa ion [8]. S uden s mus lea n o beha e in
c i ical si ua ions and make wise decisions [17]. Thus,
clinical easoning is an impo an lea ning ou come ha
equi es accu a e assessmen [3, 18]. De e mining he
clinical easoning skills o nu sing s uden s can be a
window o assessing hei abili y o make accu a e
clinical judgmen s and, hus, will help de elop
app op ia e eaching and lea ning s a egies ha p omo e
he clinical easoning skills o nu sing s uden s [19].
Acco dingly, assessing clinical easoning and decision-
making is essen ial o p epa e o u u e p o essional
asks, and a es ha aims o assess clinical compe ence
should be able o measu e, among o he hings, he
s uden 's abili y o eason clinically [20].
Howe e , he e a e di icul ies in inding an e ec i e
me hod o assessing s uden s' clinical easoning
p ocesses o diagnosis and ea men [21]. This is
because clinical easoning is highly complex, and i s
assessmen poses signi ican challenges.
Addi ionally, measu ing in e nal men al p ocesses is
inhe en ly di icul since hey a e no di ec ly obse able
[22]. The e is cu en ly a wide ange o clinical easoning
assessmen s, and he li e a u e on hese ins umen s is
widely dispe sed, making i challenging o ins uc o s o
selec and ca y ou assessmen s aligned wi h hei
speci ic goals, needs, and esou ces. These assessmen s
ha e o en been designed in di e en con ex s [23].
Hence, he la ge numbe and a ie y o clinical easoning
assessmen me hods p esen challenges in selec ing
assessmen s di ec ed a a speci ic goal [24].
Fu he mo e, when de eloping assessmen s, p inciples
such as assessmen objec i es, wha should be assessed,
how o assess, eliabili y and alidi y o es s, educa ional
impac , cos -e ec i eness, and accep abili y should be
conside ed [25-28]. U ilizing a s anda d guideline o
objec i ely assessing clinical easoning enhances
e alua ions' accu acy.
E ec i e measu emen makes i possible o de e mine
he ex en o which a esea che 's in e en ion has led o
change [29]. The e o e, a combina ion o he exis ing
e idence is necessa y o ad ance he assessmen o his
basic compe ency, and he alue o he indings o his
s udy can be be e unde s ood h ough he lens o
compe ency-based educa ion [24]. To his end, he
p esen s udy aimed o iden i y me hods o assessing
clinical easoning in nu sing s uden s.
Ma e ials & Me hods
Design and se ing(s)
This sys ema ic e iew was conduc ed using he
P e e ed Repo ing I ems o Sys ema ic Re iews and
Me a-Analyses (PRISMA) checklis .
Da a collec ion me hods (Figu e 1)
In his sys ema ic e iew, he MESH, SNOMED, and
EMBASE hesau uses and ela ed li e a u e we e
examined o selec ele an keywo ds.
Subsequen ly, a comp ehensi e sea ch using he
keywo ds "Clinical Reasoning" AND "Nu sing
S uden s" was conduc ed in he PubMed, Scopus, Web
o Science, P oQues , Magi an, and SID da abases in
May 2024 (Table 1).
I should be no ed ha g ay li e a u e was no e iewed
in his s udy.
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Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 131
Pa icipan s and sampling
Two housand eigh hund ed nine y- h ee a icles
we e e ie ed om all da abases and impo ed in o
EndNo e-9 so wa e. A e emo ing duplica es, wo
esea che s sc eened he i les and abs ac s o
ele ance and adhe ence o he inclusion c i e ia. The
a icles we e independen ly assessed by bo h
esea che s using he app op ia e ools, and he
esul s o hese e alua ions we e compa ed and
con i med du ing a join session. In cases o
disag eemen , a hi d esea che was consul ed o
u he cla i ica ion. The inclusion c i e ia we e
o iginal quan i a i e (Desc ip i e, analy ical, and
in e en ion s udies), quali a i e, and mixed-me hods
a icles published in English o Pe sian. To maximize
e ie al, no es ic ions we e applied based on he
yea o publica ion, and a icles we e sea ched om
incep ion un il May 2024. This s udy included and
e iewed esea ch a icles ha examined clinical
easoning as a a iable o p ima y ocus in nu sing
s uden popula ions. A icles ha assessed con idence
in clinical easoning o a icles ha did no ocus on
clinical easoning assessmen and did no use clinical
easoning assessmen ools we e excluded om he
s udy. Addi ionally, sho communica ion a icles,
le e s o he edi o , book e iews, e iew a icles, and
a icles o which he ull ex was no a ailable we e
excluded om he s udy.
Table 1. Keywo ds and sea ch s a egies
Sea ch
S a egy
Da abases
PubMed
("Clinical Reasoning"[Mesh] OR "Clinical Reasoning"[ iab] OR "Clinical Judgmen "[ iab] OR "Clinical Decision-Making"[Mesh]
OR "Clinical Decision-Making"[ iab] OR easoning[ iab]) AND ("Nu sing S uden s"[Mesh] OR "Nu sing S uden s"[ iab] OR
"Nu sing S uden "[ iab] OR "Pupil Nu se"[ iab]) AND ("Assessmen Me hods"[ iab] OR logbook[ iab] OR cueing[ iab] OR "m-
osce"[ iab] OR "key ea u e"[ iab] OR osce[ iab] OR "s uc u ed clinical exam"[ iab] OR "mul iple choice"[ iab] OR "s uc u ed o al
in e iew"[ iab] OR "sequen ial p oblem"[ iab] OR "sc ip conco dance"[ iab] OR "Mini-CEX"[ iab] OR "si ua ional judgmen
es "[ iab] OR "si ua ional judgemen es "[ iab] OR "pa ien managemen p oblem"[ iab] OR "ca d so "[ iab] OR e alua *[ iab] OR
assess*[ iab] OR measu *[ iab] OR ins umen [ iab] OR es *[ iab] OR essay[ iab] OR exam[ iab] OR examina ion[ iab] OR
ques ion[ iab] OR examinee[ iab] OR Simula ion[ iab] OR "Clinical Reasoning Assessmen ub ic"[ iab] OR "Vi ual pa ien s"[ iab]
OR "Heal h Sciences Reasoning Tes "[ iab] OR "IRUEPIC model"[ iab] OR "Clinical Reasoning Model"[ iab] OR "Assessmen
ools"[ iab] OR "Measu emen o Clinical Reasoning"[ iab] OR "Nu ses Clinical Reasoning Scale"[ iab] OR "Assessmen o clinical
easoning"[ iab] OR "To assess s uden s clinical easoning"[ iab])
Scopus
TITLE-ABS-KEY("Clinical Reasoning" OR "Clinical Judgmen " OR "Clinical Decision-Making" OR easoning) AND TITLE-ABS-
KEY("Nu sing S uden " OR "Pupil Nu se") AND TITLE-ABS-KEY("Assessmen Me hods" OR logbook OR cueing OR "m-osce"
OR "key ea u e" OR osce OR "s uc u ed clinical exam" OR "mul iple choice" OR "s uc u ed o al in e iew" OR "sequen ial
p oblem" OR "sc ip conco dance" OR "Mini-CEX" OR "si ua ional judgmen es " OR "si ua ional judgemen es " OR "pa ien
managemen p oblem" OR "ca d so " OR e alua * OR assess* OR measu * OR ins umen OR es * OR essay OR exam OR
examina ion OR ques ion OR examinee OR Simula ion OR "Clinical Reasoning Assessmen ub ic" OR "Vi ual pa ien s" OR
"Heal h Sciences Reasoning Tes " OR "IRUEPIC model" OR "Clinical Reasoning Model" OR "Assessmen ools" OR "Measu emen
o Clinical Reasoning" OR "Nu ses Clinical Reasoning Scale" OR "Assessmen o clinical easoning" OR "To assess s uden s clinical
easoning")
ISI
TS=("Clinical Reasoning" OR "Clinical Judgmen " OR "Clinical Decision-Making" OR easoning) AND TS=("Nu sing S uden "
OR "Pupil Nu se") AND TS=("Assessmen Me hods" OR logbook OR cueing OR "m-osce" OR "key ea u e" OR osce OR
"s uc u ed clinical exam" OR "mul iple choice" OR "s uc u ed o al in e iew" OR "sequen ial p oblem" OR "sc ip conco dance"
OR "Mini-CEX" OR "si ua ional judgmen es " OR "si ua ional judgemen es " OR "pa ien managemen p oblem" OR "ca d so "
OR e alua * OR assess* OR measu * OR ins umen OR es * OR essay OR exam OR examina ion OR ques ion OR examinee OR
Simula ion OR "Clinical Reasoning Assessmen ub ic" OR "Vi ual pa ien s" OR "Heal h Sciences Reasoning Tes " OR "IRUEPIC
model" OR "Clinical Reasoning Model" OR "Assessmen ools" OR "Measu emen o Clinical Reasoning" OR "Nu ses Clinical
Reasoning Scale" OR "Assessmen o clinical easoning" OR "To assess s uden s clinical easoning")
P oQues
ab("Clinical Reasoning" OR "Clinical Judgmen " OR "Clinical Judgemen s" OR "Clinical Decision-Making" OR easoning) AND
ab("Nu sing S uden " OR "Nu sing S uden s" OR "Pupil Nu se" OR "Pupil Nu ses") AND ab("Assessmen Me hods" OR logbook
OR cueing OR "m-osce" OR "key ea u e" OR osce OR "s uc u ed clinical exam" OR "mul iple choice" OR "s uc u ed o al
in e iew" OR "sequen ial p oblem" OR "sc ip conco dance" OR "Mini-CEX" OR "si ua ional judgmen es " OR "si ua ional
judgemen es " OR "pa ien managemen p oblem" OR "ca d so " OR "ca d so s" OR e alua OR assess OR measu OR ins umen
OR ins umen s OR es OR es s OR essay OR exam OR examina ion OR ques ion OR examinee OR Simula ion OR "Clinical
Reasoning Assessmen ub ic" OR "Vi ual pa ien s" OR "Heal h Sciences Reasoning Tes " OR "IRUEPIC model" OR "Clinical
Reasoning Model" OR "Assessmen ools" OR "Measu emen o Clinical Reasoning" OR "Nu ses Clinical Reasoning Scale" OR
"Assessmen o clinical easoning" OR "To assess s uden s clinical easoning")
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Figu e 1. PRISMA 2020 low diag am
Tools/Ins umen s
Finally, he quali y o 25 a icles was e alua ed using
assessmen ools i ing he s udy design. The quali a i e
a icles we e assessed using he C i ical App aisal Skills
P og amme (CASP) ool o quali a i e s udies (10 i ems
- Table 2). In e en ional a icles we e e alua ed using
he CASP ool o clinical ial s udies (11 i ems - Table
3), while mixed me hods s udies we e assessed wi h he
5-i em Mixed Me hods App aisal Tool (MMAT - Table
4). Desc ip i e a icles we e e iewed using he Joanna
B iggs Ins i u e (JBI) ool (8 i ems - Table 5), and non-
clinical ials we e assessed wi h he Mino ool (12 i ems
- Table 6).
Table 2. Quali y quali a i e s udies
Fi s au ho , yea
Eleni a Fo sbe g,
2015 [72]
Ca ina Geo g,
2018 [73]
Clea aims?
✓
✓
Quali a i e me hodology
app op ia e?
✓
✓
Resea ch design app op ia e
o add ess aims?
✗
✓
App op ia e ec ui men
s a egy?
✗
✓
Da a collec ion app op ia e?
✗
✗
Rela ionship be ween
esea che and pa icipan s
conside ed?
✗
✗
E hical issues conside ed?
✓
✓
Da a analysis su icien ly
igo ous?
✗
✗
Clea s a emen o indings?
✗
✗
Valuable esea ch?
✗
✗
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Table 3. Quali y clinical ial s udies
Fi s au ho , yea
Goui ane e al., 2020 [52]
Blanié e al.,2020 [41]
Did he ial add ess a clea ques ion?
✓
✓
Was he assignmen o pa ien s o ea men s andomised?
✗
✓
We e all o he pa ien s who en e ed he ial p ope ly accoun ed o a
i s conclusion?
✓
✓
We e pa ien s, heal h wo ke s, and s udy pe sonnel ‘blind’ o ea men ?
✗
✓
We e he g oups simila a he s a o he ial?
✓
✓
Aside om he expe imen al in e en ion, we e he g oups ea ed
equally?
✗
✗
How la ge was he ea men e ec ?
✓
✓
How p ecise a e he es ima es o he ea men e ec ?
✗
✓
Can he esul s be applied o he local popula ion?
✓
✓
We e all clinically impo an ou comes conside ed?
✓
✓
A e he bene i s wo h he ha ms and cos s?
✓
✓
Table 4. Quali y mixed me hod s udy
Fi s au ho , yea
Is he e an adequa e
a ionale o using a
mixed me hods design
o add ess he esea ch
ques ion?
A e he di e en
componen s o he
s udy e ec i ely
in eg a ed o
answe he esea ch
ques ion?
A e he ou pu s o
he in eg a ion o
quali a i e and
quan i a i e
componen s
adequa ely
in e p e ed?
A e di e gences
and inconsis encies
be ween
quan i a i e and
quali a i e esul s
adequa ely
add essed?
Do he di e en
componen s o he
s udy adhe e o he
quali y c i e ia o
each adi ion o he
me hods in ol ed?
Cheng e al., 2024
[31]
yes
yes
yes
yes
yes
Johns on e al., 2019
[34]
yes
yes
yes
yes
yes
Table 5. Quali y c oss-sec ional s udies
Fi s au ho ,
yea
Was he
s udy
based on
a andom
o
pseudo-
andom
sample?
We e he
c i e ia
o
inclusion
in he
sample
clea ly
de ined?
We e
con ounding
ac o s
iden i ied
and
s a egies o
deal wi h
hem
s a ed?
We e
ou comes
assessed
using
objec i e
c i e ia?
We e g oup
desc ip ions
su icien in
compa isons?
Was
ollow up
ca ied
ou o e a
su icien
ime
pe iod
We e he
ou comes
o people
who
wi hd ew
desc ibed
and
included
in he
analysis
We e
ou comes
measu ed
in a
eliable
way
Was
app op ia e
s a iscal
analysis
used
Kuipe e al.,
2009 [5]
Yes
No
No
No
No
No
No
Yes
No
Kuipe e al.,
2008 [8]
Yes
Yes
No
No
No
No
No
Yes
No
Damoda an e
al., 2023 [42]
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Hong e al.,
2021[32]
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Khanyile e
al., 2005 [67]
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Koi is o e al.,
2016[69]
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Da a analysis
Based on he esea ch eam membe s' decision, a icles
accep ed o inal e alua ion needed o achie e a sco e o
a leas 50% o he o al possible poin s. Two esea che s
e iewed and a ed all a icles, sha ing he esul s and
eaching an ag eemen . A hi d a e esol ed any
disag eemen be ween he wo a e s.
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134 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025
Resul s
In he quali y assessmen , i e a icles did no mee he
c i e ia o inclusion in he s udy, esul ing in a inal
selec ion o 20 a icles o analysis (Figu e 1). The
quali y s a us o he me hodology o hese 20 app o ed
s udies is de ailed in Tables 2 o 6.
Table 6. Quali y non andomized s udies
Fi s au ho
yea
Applicable in non-compa a i e s udies
Applicable in compa a i e
s udies)
sco e
Clea ly
s a ed aim
Inclusion o
consecu i e
pa ien s
P ospec i e
collec ion o
da a
Endpoin s
app op ia e
o he aim o
he s udy
Unbiased
assessmen o
he s udy
endpoin
Follow-up
pe iod
app op ia e
o he aim o
he s udy
Loss o
ollow-up less
han 5%
P ospec i e
calcula ion o
he s udy size
Adequa e
con ol
g oup
Con empo a
y g oups
Baseline
equi alence
o g oups
Adequa e
s a is ical
analysis
Son HK e
al., 2023 [60]
2
2
2
2
2
2
2
2
No
applicable
No
applicable
No
applicable
No
applicable
16/16
Ma comini
e al., 2021
[35]
2
2
2
2
2
0
0
1
No
applicable
No
applicable
No
applicable
No
applicable
11/16
Kau z e al.,
2005 [64]
2
2
2
2
0
2
0
1
No
applicable
No
applicable
No
applicable
No
applicable
11/16
Hosseini e
al., 2021 [53]
1
2
2
2
0
0
2
1
No
applicable
No
applicable
No
applicable
No
applicable
10/16
A isudhana
e al., 2022
[47]
2
2
2
2
0
2
2
2
2
2
2
2
22/24
Fo ne is e
al., 2015
[48]
2
1
2
2
0
0
2
2
2
2
2
2
19/22
A isudhana
e al., 2022
[46]
2
2
2
2
0
2
2
2
2
2
2
2
22/24
Hu e al.
2021 [33]
2
2
2
2
0
2
2
2
2
2
2
2
22/24
Kim e al.,
2015 [59]
2
2
2
2
0
2
2
2
2
2
2
2
22/24
Moghadam
e al., 2019
[68]
2
0
2
2
0
2
2
2
2
2
2
2
20/24
Seo e al.,
2021 [63]
2
2
2
2
0
2
2
2
2
2
2
2
22/24
de Sá Tinôco
e al., 2021
[71]
2
2
2
2
0
0
0
2
2
2
2
2
18/24
Yau i e al.,
2019 [70]
2
2
2
2
0
1
2
2
2
2
2
2
21/24
This e iew comp ised 20 a icles (Table 7), including
12 in e en ional s udies, wo clinical ial a icles, ou
desc ip i e c oss-sec ional s udies, and wo mixed-
me hods a icles. The indings e ealed ha i e a icles
u ilized he Nu ses Clinical Reasoning Scale (NCRS)
(25%), wo a icles employed Sc ip Conco dance Tes s
(SCTs) (10%), wo a icles applied he key ea u e es
(10%), wo a icles used he Ou come-P esen S a e Tes
(10%), wo a icles implemen ed ub ics (10%), wo
a icles adop ed he iple jump exe cise (10%), one
a icle used he Heal h Sciences Reasoning Tes (HSRT)
(5%), one a icle applied scena ios (5%), one a icle
employed he Clinical Reasoning Assessmen Tool (5%),
and one a icle u ilized a esea che -made ques ionnai e
(5%). Addi ionally, he indings indica ed ha en
a icles (47.61%) did no epo he ins umen s' alidi y,
while six a icles did no indica e he eliabili y o he
ins umen s. Mo eo e , no s udies epo ed he
quali a i e assessmen o nu sing s uden s' clinical
easoning. In addi ion, no s udy poin ed o he
accep abili y, cos s, o cos -e ec i eness o clinical
easoning assessmen ools.
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Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 135
Table 7. A e iew o he s udies conduc ed on clinical easoning assessmen ools
Row
Au ho (s), Yea , Coun y
S udy design
Clinical easoning
assessmen ool
Assessmen objec i e
Reliabili y & Validi y
1
Blanié e al., 2020, F ance
[41]
Expe imen al
Sc ip Conco dance Tes
(SCT)
Compa e simula ion by gaming s.
adi ional eaching o de ec ing
pa ien de e io a ion
Expe -con i med eliabili y;
C onbach’s alpha = 0.75
2
Damoda an e al., 2023,
India[42]
Desc ip i e
Sc ip Conco dance Tes
(SCT)
Compa e clinical easoning
be ween BSc and pos -basic nu sing
s uden s o in o m cu iculum
s a egies
Reliabili y con i med by 6
obs e icians, 3 nu ses, and
15 midwi es
3
A isudhana, 2022,
Indonesia[47]
Quasi-
expe imen al
Clinical Reasoning
Assessmen Tool
E ec o disease sc ip aining on
nu sing s uden s’ clinical easoning
Expe -con i med eliabili y
= 0.72; C onbach’s alpha =
0.82
4
Cheng e al., 2024, Taiwan
[31]
Mixed
me hods
Nu ses Clinical
Reasoning Scale
(NCRS)
E ec s o un olding case s udies on
clinical easoning and eam
collabo a ion
C onbach’s alpha = 0.98
5
Fo ne is e al., 2015,
USA[48]
Quasi-
expe imen al
Heal h Sciences
Reasoning Tes (HSRT)
Replica e indings on inc easing
clinical easoning h ough
s uc u ed explana ion
Coe icien o eliabili y
(Kude -Richa dson 20);
In e nal consis ency = 0.77–
0.84; Validi y con i med in
o iginal s udy (Facione &
Facione, 2006)
6
Goui ane e al., 2020,
Mo occo [52]
Expe imen al
Key Fea u e Tes
E ec o blended lea ning in blood
ans usion cou se on clinical
easoning
No epo ed
7
Hong e al., 2021, Sou h
Ko ea[32]
C oss-
sec ional
Nu ses Clinical
Reasoning Scale
(NCRS)
Fac o s a ec ing s uden s' clinical
easoning
C onbach’s alpha = 0.85
8
Hu e al., 2021, China [33]
Quasi-
expe imen al
Nu ses Clinical
Reasoning Scale
(NCRS)
Impac o iage simula ion aining
on s uden s’ clinical easoning
C onbach’s alpha = 0.937
9
Johns on e al., 2019,
Aus alia [34]
Mixed
me hods
Nu ses Clinical
Reasoning Scale
(NCRS)
Impac o simula ion deb ie ing on
s uden s’ pe cep ions o easoning
and lea ning ans e
C onbach’s alpha = 0.9
10
Kau z e al., 2005,
USA[64]
Quasi-
expe imen al
Ou come-P esen S a e
Tes (OPT)
P omo e clinical easoning ia he
OPT model
No epo ed
11
Hosseini e al., 2005, I an
[53]
Quasi-
expe imen al
Key Fea u e Tes
E alua e pha macology simula ion
aining on clinical easoning
Con en alidi y con i med
by 10 subjec -ma e expe s
12
Khanyile & M idi, 2005,
S. A ica[67]
Compa a i e-
desc ip i e
T iple Jump Exe cise
Compa e PBL s. adi ional
me hods o de eloping clinical
easoning
In e nal consis ency and
in e - a e eliabili y
con i med; Con en alidi y
suppo ed
13
Kim e al., 2015, Sou h
Ko ea[59]
Quasi-
expe imen al
Rub ic
E ec o one- ime simula ion on
easoning, knowledge, and
con idence
Expe -con i med eliabili y;
C onbach’s alpha = 0.70–
0.72
14
Koi is o e al., 2016,
Finland[69]
C oss-
sec ional
desc ip i e
Resea che -made
Ques ionnai e
Explo e s uden expe ience using
3D games o clinical easoning
Expe -con i med eliabili y;
C onbach’s alpha = 0.647–
0.832
15
Ma comini e al., 2021,
I aly[35]
Quasi-
expe imen al
Nu ses Clinical
Reasoning Scale
(NCRS)
E ec o open case s udies wi h
game elemen s on easoning
C onbach’s alpha = 0.92
16
Moghadam, 2019, I an[68]
Quasi-
expe imen al
T iple Jump Exe cise
Diagnose pa ien s om scena ios
and o mula e nu sing diagnoses
Expe -con i med eliabili y;
C onbach’s alpha = 0.87
17
Seo e al., 2021, Sou h
Ko ea[63]
Quasi-
expe imen al
Ou come-P esen S a e
Tes (OPT)
Simula ion-based aining e ec s on
easoning, p oblem-sol ing, and
compe ency
C onbach’s alpha = 0.88
18
Son HK, 2023, Sou h
Ko ea [60]
Quasi-
expe imen al
Rub ic
E ec o simula ion wi h PBL on
easoning and con inuous
assessmen
C onbach’s alpha = 0.95
o e all; Subscales: No icing
(0.89), In e p e a ion (0.80),
Responding (0.89),
Re lec ion (0.81)
19
Tinôco e al., 2021, B azil
[71]
Quasi-
expe imen al
Clinical Case Solu ion
De e mine easoning le els based
on co ec case esponses
No epo ed
20
Yau i, 2019, Indonesia[70]
Quasi-
expe imen al
Clinical Scena ios
Imp o e clinical easoning using
con ex ualized guided lea ning
Con en alidi y con i med
by expe s and s uden
sample
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136 Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025
Discussion
In his sec ion, 10 iden i ied ools o assessing clinical
easoning a e p esen ed sepa a ely:
The Nu ses Clinical Reasoning Scale
(NCRS)
The e iew da a indica ed ha he mos equen ly used
clinical easoning assessmen ool was he NCRS. This
scale, de eloped by Liou e al., is a ailable in Chinese
and consis s o 15 i ems sco ed on a 5-poin Like scale.
The o al sco e anges om 25 o 75, wi h highe sco es
e lec ing a highe le el o clinical easoning. The
con en alidi y o his ool was con i med wi h a
Con en Validi y Index (CVI) o 1. The cons uc alidi y
o he ool was examined h ough ac o analysis, and 15
i ems we e con i med. The ins umen 's eliabili y was
e alua ed and con i med wi h C onbach's alpha
coe icien o 0.7, an in e nal consis ency coe icien o
0.7, and an In aclass Co ela ion Coe icien (ICC)
alue o 0.85. I is wo h no ing ha his ins umen 's
in e p e a ion o clinical easoning is limi ed because i
measu es sel -pe cei ed compe encies a he han
p o en p ac ical compe encies in clinical easoning
[30].This ins umen was used in i e s udies conduc ed
in Taiwan [31], Ko ea [32], China [33], Aus alia [34],
and I aly [35]. The s udies om Taiwan, Ko ea, and
China only add essed he psychome ic p ope ies o he
o iginal e sion o he ins umen , ocusing solely on i s
eliabili y. The epo ed eliabili y alues o hese
s udies we e 0.98 [30], 0.85 [32], and 0.93 [33],
espec i ely. A s udy conduc ed in Aus alia only
e e ed o he pe mission o he ins umen and did no
assess o epo he alidi y and eliabili y o he scale
[34]. Addi ionally, a s udy conduc ed in I aly did no
epo he scale's alidi y bu assessed and con i med i s
eliabili y, yielding C onbach's alpha coe icien o 0.90
[35]. Since da a collec ion is conside ed one o he mos
impo an s ages in a esea ch p ojec , i equi es eliable
and alid ins umen s [1]. Thus, eliable esul s canno be
ex ac ed om da a collec ed wi h li le p ecision. Fo
his eason, da a should be collec ed wi h alid
ins umen s i ing he cul u al con ex o he esea ch
popula ion. Howe e , i no such ins umen exis s, a
alid and eliable ins umen i ing he cul u al con ex
o he communi y in ques ion should be ansla ed and
used [36]. S udies by Cheng [31], Hu [33], and Johns on
[34] ha e highligh ed he limi a ions o his ool,
pa icula ly conce ning he sel - epo ing na u e o
s uden s' clinical easoning, which quali ies i as a
subjec i e o m o e alua ion.
Sc ip Conco dance Tes s
)
SCTs
(
The second ool was sc ip conco dance es s, which a e
e ec i e o assessing clinical easoning. Based on sc ip
heo y [37], hese es s a e de eloped based on cogni i e
psychology, which posi s ha heal hca e p o ide s
o ganize, s o e, and access hei knowledge h ough
"disease sc ip s." These "sc ip s" allow he indi idual o
use pa e n ecogni ion and p e ious clinical expe ience
o make decisions du ing pa ien ca e [38]. SCTs
e alua e s uden s's uden s' clinical easoning in
condi ions o unce ain y wi hin complex si ua ions [39].
I is impo an o no e ha SCTs do no analyze he
s uden s' p oblem-sol ing app oaches bu assess whe he
he ou comes align wi h expe opinions. This is whe e
he unique alue o using such es s o measu e clinical
easoning skills lies. One s eng h o SCTs is ha a ious
media, including images, audio, and ideos, can be
inco po a ed in o he scena ios, allowing hem o closely
eplica e eal-li e si ua ions. Howe e , de eloping
scena ios o measu e clinical easoning ins ead o
knowledge is di icul . Mo eo e , i is also no easy o
access expe s who can sco e he esponses [40]. The
e iew da a showed ha wo s udies on nu sing s uden s
used SCTs o assess clinical easoning. Blanié e al.
de eloped a sc ip conco dance es based on he
amewo ks o Cha lin e al. and Fo ne is e al., which
demons a ed con i med alidi y; he eliabili y o he
es was es ablished wi h a C onbach'sC onbach's alpha
coe icien o 75% [41]. Rega ding he limi a ions o he
ool, Blanié no es ha i equi es p io aining be o e
use, and he eliance on sel - epo ing by s uden s may
diminish da a eliabili y. In a s udy by Damoda an e al.,
he de eloped scena ios we e gi en o a panel o expe s
o answe he i ems in he scena ios and con i m he
alidi y o he scena ios [42]. I is impo an o no e ha
SCTs should be e alua ed by 10 o 20-panel membe s o
enhance he accu acy o he es and ensu e adequa e
eliabili y. Fo a eliable es , i is necessa y o de elop
25 scena ios and inco po a e ou i ems o each scena io
[43]. Schola s belie e ha SCTs ha e good accep ance
as a ool o measu ing clinical easoning because hey
e lec eal clinical si ua ions. Fu he mo e, aining
s uden s abou his ype o es and e-adminis e ing i
can help imp o e hei unde s anding o sc ip
conco dance es s [44]. Conside ing ha a e y limi ed
numbe o s udies ha e explo ed using SCTs in nu sing,
hese assessmen s ha e no ga ne ed signi ican a en ion
in his ield [45].
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Jou nal o Medical Educa ion De elopmen ¦ Volume 18 ¦ Issue 2 ¦ 2025 137
Clinical Reasoning Assessmen Tool
The nex ool is he Clinical Reasoning Assessmen Tool,
de eloped by A isudana and Puspawai in Indonesian.
This ool consis s o 36 i ems sco ed on a 3-poin Like
scale, wi h o al sco es anging om 25 o 75. The ool's
eliabili y has been con i med wi h C onbach's alpha
coe icien o 82%, while i s speci ici y is epo ed a
65%, and i s p ecision is es ima ed a 72%. Addi ionally,
he ool's alidi y has been es ablished [46]. Howe e , in
a s udy conduc ed in Indonesia, i was only u ilized by i s
de elope s, A isudana and Ma ini. This s udy iden i ied
a po en ial esponse bias om s uden s as a limi a ion
due o he sel - epo na u e o he clinical easoning
assessmen [47].
Heal h Sciences Reasoning Tes (HSRT)
The ou h ool is he HSRT. This ool was used by
Fo ne is e al. in Minneso a. The HSRT is a mul iple-
choice es consis ing o 33 i ems, ea u ing a a ie y o
scena ios in clinical and p o essional con ex s wi h
in o ma ion p esen ed in bo h ex and g aphic o ma s.
The i ems on his es equi e es ake s o apply hei
skills o in e p e in o ma ion, analyze da a, d aw alid
in e ences, iden i y claims and easons, and e alua e he
quali y o a gumen s. The ool's eliabili y has been
es ablished wi h a coe icien o ep oducibili y o 20,
while i s in e nal consis ency is suppo ed by C onbach's
alpha coe icien , which anges om 0.77 o 0.84. A
limi a ion o his ool is ha i is no speci ically designed
o nu sing o nu sing s uden s; a he , i aims o assess
heal h p o essionals, which may limi i s e ec i eness in
e alua ing clinical easoning in nu sing s uden s [48].
Key Fea u e
The Key Fea u e Tes is he i h ool. I is a w i en o
elec onic es in which a sho scena io con aining key
and non-key componen s is p esen ed, and he candida e
mus make a clinical decision based on i . Fo example,
he candida e migh need o de e mine wha key indings
a e necessa y o diagnosis and wha ac ions should be
p io i ized o he pa ien 's clinical managemen . The
esponses o he i ems can be ei he b ie answe s o
selec ions om a lis [49]. To ensu e ha a key ea u e
es possesses good ace and con en alidi y, he i ems
should be de eloped based on a bluep in ha clea ly
ou lines he main ocuses [50, 51]. The e iew da a
indica ed ha his ool has been u ilized in wo s udies.
Goui ane e al. designed 30 key ea u e i ems based on
he clinical case o blood ans usion, enabling s uden s
o iden i y ele an clues by linking in o ma ion and
sea ching o missing de ails, c ea ing hypo heses and
clinical judgmen s, and ul ima ely making e ec i e
clinical decisions wi h app op ia e explana ions.
Goui ane no ed he limi ed ease o applying he ool in
clinical se ings [52]. Simila ly, Hosseini e al. de eloped
and employed 15 key ea u e ques ions o assess nu sing
s uden s' clinical easoning in a clinical pha macology
cou se [53].
Rub ic
The ub ic is he six h ool. A ub ic is a cohe en se o
speci ic c i e ia desc ibing he quali a i e pe o mance
le el [54]. I unc ions as a bluep in ha ou lines he
mas e y o a skill [55] and is ega ded as a alid and
eliable ool o ins uc o s [56], p o ided ha he
de eloped ub ic possesses s ong alidi y [51]. I s
alidi y should be e alua ed and con i med by expe s,
including nu sing educa ion expe s, clinical ins uc o s,
and s uden s as s akeholde s [57]. Rub ics can acili a e
he assessmen o clinical easoning in unde g adua e
s uden s om hei i s yea h ough hei in e nship.
They can also s eng hen s uden s' capaci y o sel -
assessmen so ha hey can de elop e ec i e hinking
skills and p o ide ins uc o s wi h he oppo uni y o
moni o hei imp o emen o clinical easoning skills.
Ins uc o s can s eng hen his skill in s uden s by
p o iding imely and e ec i e eedback. Rub ics can be
u ilized in a ious educa ional con ex s, including online
cou ses, eal-wo ld se ings, and clinical educa ion [57,
58]. The da a showed ha wo s udies ha e used ub ics.
Based on a li e a u e e iew and expe opinions, Kim e
al. designed a ub ic ha consis ed o 4 sec ions: da a
collec ion, diagnosis, p oblem p io i iza ion, and
planning, and hese sec ions we e ela ed o he s eps o
he nu sing p ocess. In his ub ic, each s ep had a
desc ip ion o he s uden 's pe o mance and a sco e
ange, and he o al s uden sco e anged om 2 o 10.
Thus, he ins uc o could ob ain in o ma ion abou he
s uden 's clinical easoning s a us. Kim e al. indica ed
ha he alidi y o his me hod diminishes i only a single
acili a o is used, making his a key limi a ion o he ool
[59]. In hei s udy, Son e al. used a ub ic de eloped by
Tanne . This ub ic consis ed o ou sec ions: no icing
(3 i ems abou unde s anding he pa ien 's condi ion and
ele an in o ma ion), in e p e ing (2 i ems abou
in e p e ing he pa ien 's condi ion and ele an
in o ma ion), esponding (3 i ems abou es ablishing
appo wi h he pa ien ), and gi ing eedback (2 i ems
abou e lec ing on nu sing p ac ice). The ub ic had 10
i ems wi h a o al sco e anging om 10 o 40 ha
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