A systematic review of methods for assessing clinical reasoning in nursing students

Copyright © 2025 Zanjan University of Medical Sciences. Published by Zanjan University of Medical Sciences. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International license (https://creativecommons.org/licenses/bync/4.0/). Noncommercial uses of the work are permitted, provided the original work is properly cited. A systematic review of methods for assessing clinical reasoning in nursing students Naiire Salmani1, Imane Bagheri 2* 1National Agency for Strategic Research in Medical Education, Tehran, Iran 2 Faculty of Nursing and Midwifery, Research Center for Nursing and Midwifery Care, Non-communicable Diseases Research Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran Article info Abstract Introduction In any educational system, moving learners from memorization to reasoning (an innovative way to solve problems) is a fundamental issue [1]. Reasoning is a thinking process that transforms an undesirable or problematic situation into a desirable one by processing the subject matter [2]. Clinical reasoning is one of the important and essential skills in nursing education and practice [3, 4]. Clinical reasoning in nursing is a cognitive process that nurses use to collect, synthesize, and understand information [3] and identify and diagnose patient problems [5] to guide decisions about patient care [3]. In other words, clinical reasoning is the ability of a nurse to look at a large volume of data and then accurately identify and apply effective nursing practices to address the problems identified during patient care [6]. Clinical reasoning is of great importance for learning and developing nursing care. The effective use of clinical reasoning in complex care situations is currently one of the healthcare requirements for rapid Article history: Received 7 Dec. 2024 Accepted 21 Aug. 2025 Published 13 Jul. 2025 Salmani et al. J Med Edu Dev. 2025; 18(2): 129-143 Journal of Medical Education Development Background & Objective: Nursing instructors can play a crucial role in enhancing students' clinical reasoning skills by evaluating them and offering timely, constructive feedback. Therefore, identifying effective clinical reasoning assessment tools is vital for accomplishing this objective. To this end, this study aimed to review the methods for assessing clinical reasoning in nursing students. Materials & Methods: This systematic review was conducted in May 2024 using the keywords "Clinical Reasoning" and "Nursing Students." Eligible articles published in both English and Persian were systematically searched in various national and international online databases, including SID, Magiran, Scopus, Web of Science, PubMed, and ProQuest. Results: A total of 2893 articles were retrieved from the initial search findings. After removing duplicates and irrelevant articles based on the inclusion criteria, a qualitative assessment was conducted using the Critical Appraisal Skills Programme (CASP), the Mixed Methods Appraisal Tool (MMAT), and the Joanna Briggs Institute (JBI) checklists. Ultimately, 20 articles on clinical reasoning assessment tools for nursing students were reviewed. The findings revealed that researchers utilize a range of tools to assess clinical reasoning, with the most common being the Nurses Clinical Reasoning Scale (NCRS), Script Concordance Tests (SCTs), key feature tests, Outcome-Present State Test (OPT), rubrics, and the triple jump exercise. However, the validity and reliability of the tools used and their acceptability and costeffectiveness have not been assessed in the literature. Conclusion: The findings indicated that the NCRS is the most commonly used assessment tool. Therefore, conducting psychometric evaluations of this tool in Iran is recommended. Furthermore, longitudinal studies are needed to evaluate the impact of clinical reasoning assessment tools on nursing students and explore how these tools can be effectively integrated into nursing curricula. Keywords: nursing students, clinical reasoning, systematic review, clinical reasoning tools, nursing education *Corresponding author: Imane Bagheri, A systematic review of methods for assessing clinical reasoning in nursing students. Email: [email protected] Review Article How to cite this article: Salmani N, Bagheri I. A systematic review of methods for assessing clinical reasoning in nursing students. J Med Edu Dev. 2025; 18(2): 129-143. [ DOI: 10.61882/edcj.18.2.129 ] [ Downloaded from edujournal.zums.ac.ir on 2025-10-03 ] 1 / 15 Salmani et al . : Assessing clinical reasoning in nursing students 130 Journal of Medical Education Development ¦ Volume 18 ¦ Issue 2 ¦ 2025 assessment of care needs and provision of high-quality care [3, 4]. Clinical reasoning helps nurses make the most accurate decisions in clinical settings and provide personcentered, high-quality, effective, and safe patient care [710]. In other words, nurses with adequate clinical reasoning skills positively impact patient care outcomes [11]. However, a literature review suggests nurses often have limited clinical reasoning skills and use various cognitive strategies [12, 13]. The most commonly used skill was checking for accuracy and reliability. The reasoning process of nurses encompasses the phases of assessment, analysis, diagnosis, planning/implementation, and evaluation [14]. Nurses with inadequate clinical reasoning skills find decision-making complex, with their ability to triage patients showing accuracy rates ranging from 22% to 89% [12, 13]. These nurses often cannot recognize situations where the patient's condition deteriorates and fails to save the patient [11]. Poor clinical reasoning skills can lead to poor diagnosis, failure to provide effective treatment, inappropriate management, and adverse patient outcomes [15]. In other words, the occurrence of hospital complications in patients is directly related to the quality of care and the clinical reasoning skills of caregivers [16]. Therefore, developing clinical reasoning skills before nurses enter the clinical field is necessary [7, 8]. Strengthening clinical reasoning for nursing students is a goal of nursing education [5] and is considered an important topic in nursing programs and learning outcomes [13]. Nursing instructors are responsible for assessing students' understanding of the logic of clinical actions, and one of the primary goals of clinical nursing educators is to develop clinical reasoning skills in students and bridge the gap between theoretical and practical education [8]. Students must learn to behave in critical situations and make wise decisions [17]. Thus, clinical reasoning is an important learning outcome that requires accurate assessment [3, 18]. Determining the clinical reasoning skills of nursing students can be a window to assessing their ability to make accurate clinical judgments and, thus, will help develop appropriate teaching and learning strategies that promote the clinical reasoning skills of nursing students [19]. Accordingly, assessing clinical reasoning and decisionmaking is essential to prepare for future professional tasks, and a test that aims to assess clinical competence should be able to measure, among other things, the student's ability to reason clinically [20]. However, there are difficulties in finding an effective method for assessing students' clinical reasoning processes for diagnosis and treatment [21]. This is because clinical reasoning is highly complex, and its assessment poses significant challenges. Additionally, measuring internal mental processes is inherently difficult since they are not directly observable [22]. There is currently a wide range of clinical reasoning assessments, and the literature on these instruments is widely dispersed, making it challenging for instructors to select and carry out assessments aligned with their specific goals, needs, and resources. These assessments have often been designed in different contexts [23]. Hence, the large number and variety of clinical reasoning assessment methods present challenges in selecting assessments directed at a specific goal [24]. Furthermore, when developing assessments, principles such as assessment objectives, what should be assessed, how to assess, reliability and validity of tests, educational impact, cost-effectiveness, and acceptability should be considered [25-28]. Utilizing a standard guideline for objectively assessing clinical reasoning enhances evaluations' accuracy. Effective measurement makes it possible to determine the extent to which a researcher's intervention has led to change [29]. Therefore, a combination of the existing evidence is necessary to advance the assessment of this basic competency, and the value of the findings of this study can be better understood through the lens of competency-based education [24]. To this end, the present study aimed to identify methods for assessing clinical reasoning in nursing students. Materials & Methods Design and setting(s) This systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Data collection methods (Figure 1) In this systematic review, the MESH, SNOMED, and EMBASE thesauruses and related literature were examined to select relevant keywords. Subsequently, a comprehensive search using the keywords "Clinical Reasoning" AND "Nursing Students" was conducted in the PubMed, Scopus, Web of Science, ProQuest, Magiran, and SID databases in May 2024 (Table 1). It should be noted that gray literature was not reviewed in this study. [ DOI: 10.61882/edcj.18.2.129 ] [ Downloaded from edujournal.zums.ac.ir on 2025-10-03 ] 2 / 15 Salmani et al . : Assessing clinical reasoning in nursing students Journal of Medical Education Development ¦ Volume 18 ¦ Issue 2 ¦ 2025 131 Participants and sampling Two thousand eight hundred ninety-three articles were retrieved from all databases and imported into EndNote-9 software. After removing duplicates, two researchers screened the titles and abstracts for relevance and adherence to the inclusion criteria. The articles were independently assessed by both researchers using the appropriate tools, and the results of these evaluations were compared and confirmed during a joint session. In cases of disagreement, a third researcher was consulted for further clarification. The inclusion criteria were original quantitative (Descriptive, analytical, and intervention studies), qualitative, and mixed-methods articles published in English or Persian. To maximize retrieval, no restrictions were applied based on the year of publication, and articles were searched from inception until May 2024. This study included and reviewed research articles that examined clinical reasoning as a variable or primary focus in nursing student populations. Articles that assessed confidence in clinical reasoning or articles that did not focus on clinical reasoning assessment and did not use clinical reasoning assessment tools were excluded from the study. Additionally, short communication articles, letters to the editor, book reviews, review articles, and articles for which the full text was not available were excluded from the study. Table 1. Keywords and search strategies Search Strategy Databases PubMed ("Clinical Reasoning"[Mesh] OR "Clinical Reasoning"[tiab] OR "Clinical Judgment"[tiab] OR "Clinical Decision-Making"[Mesh] OR "Clinical Decision-Making"[tiab] OR reasoning[tiab]) AND ("Nursing Students"[Mesh] OR "Nursing Students"[tiab] OR "Nursing Student"[tiab] OR "Pupil Nurse"[tiab]) AND ("Assessment Methods"[tiab] OR logbook[tiab] OR cueing[tiab] OR "mosce"[tiab] OR "key feature"[tiab] OR osce[tiab] OR "structured clinical exam"[tiab] OR "multiple choice"[tiab] OR "structured oral interview"[tiab] OR "sequential problem"[tiab] OR "script concordance"[tiab] OR "Mini-CEX"[tiab] OR "situational judgment test"[tiab] OR "situational judgement test"[tiab] OR "patient management problem"[tiab] OR "card sort"[tiab] OR evaluat*[tiab] OR assess*[tiab] OR measur*[tiab] OR instrument[tiab] OR test*[tiab] OR essay[tiab] OR exam[tiab] OR examination[tiab] OR question[tiab] OR examinee[tiab] OR Simulation[tiab] OR "Clinical Reasoning Assessment rubric"[tiab] OR "Virtual patients"[tiab] OR "Health Sciences Reasoning Test"[tiab] OR "IRUEPIC model"[tiab] OR "Clinical Reasoning Model"[tiab] OR "Assessment tools"[tiab] OR "Measurement of Clinical Reasoning"[tiab] OR "Nurses Clinical Reasoning Scale"[tiab] OR "Assessment of clinical reasoning"[tiab] OR "To assess students clinical reasoning"[tiab]) Scopus TITLE-ABS-KEY("Clinical Reasoning" OR "Clinical Judgment" OR "Clinical Decision-Making" OR reasoning) AND TITLE-ABSKEY("Nursing Student" OR "Pupil Nurse") AND TITLE-ABS-KEY("Assessment Methods" OR logbook OR cueing OR "m-osce" OR "key feature" OR osce OR "structured clinical exam" OR "multiple choice" OR "structured oral interview" OR "sequential problem" OR "script concordance" OR "Mini-CEX" OR "situational judgment test" OR "situational judgement test" OR "patient management problem" OR "card sort" OR evaluat* OR assess* OR measur* OR instrument OR test* OR essay OR exam OR examination OR question OR examinee OR Simulation OR "Clinical Reasoning Assessment rubric" OR "Virtual patients" OR "Health Sciences Reasoning Test" OR "IRUEPIC model" OR "Clinical Reasoning Model" OR "Assessment tools" OR "Measurement of Clinical Reasoning" OR "Nurses Clinical Reasoning Scale" OR "Assessment of clinical reasoning" OR "To assess students clinical reasoning") ISI TS=("Clinical Reasoning" OR "Clinical Judgment" OR "Clinical Decision-Making" OR reasoning) AND TS=("Nursing Student" OR "Pupil Nurse") AND TS=("Assessment Methods" OR logbook OR cueing OR "m-osce" OR "key feature" OR osce OR "structured clinical exam" OR "multiple choice" OR "structured oral interview" OR "sequential problem" OR "script concordance" OR "Mini-CEX" OR "situational judgment test" OR "situational judgement test" OR "patient management problem" OR "card sort" OR evaluat* OR assess* OR measur* OR instrument OR test* OR essay OR exam OR examination OR question OR examinee OR Simulation OR "Clinical Reasoning Assessment rubric" OR "Virtual patients" OR "Health Sciences Reasoning Test" OR "IRUEPIC model" OR "Clinical Reasoning Model" OR "Assessment tools" OR "Measurement of Clinical Reasoning" OR "Nurses Clinical Reasoning Scale" OR "Assessment of clinical reasoning" OR "To assess students clinical reasoning") ProQuest ab("Clinical Reasoning" OR "Clinical Judgment" OR "Clinical Judgements" OR "Clinical Decision-Making" OR reasoning) AND ab("Nursing Student" OR "Nursing Students" OR "Pupil Nurse" OR "Pupil Nurses") AND ab("Assessment Methods" OR logbook OR cueing OR "m-osce" OR "key feature" OR osce OR "structured clinical exam" OR "multiple choice" OR "structured oral interview" OR "sequential problem" OR "script concordance" OR "Mini-CEX" OR "situational judgment test" OR "situational judgement test" OR "patient management problem" OR "card sort" OR "card sorts" OR evaluat OR assess OR measur OR instrument OR instruments OR test OR tests OR essay OR exam OR examination OR question OR examinee OR Simulation OR "Clinical Reasoning Assessment rubric" OR "Virtual patients" OR "Health Sciences Reasoning Test" OR "IRUEPIC model" OR "Clinical Reasoning Model" OR "Assessment tools" OR "Measurement of Clinical Reasoning" OR "Nurses Clinical Reasoning Scale" OR "Assessment of clinical reasoning" OR "To assess students clinical reasoning") [ DOI: 10.61882/edcj.18.2.129 ] [ Downloaded from edujournal.zums.ac.ir on 2025-10-03 ] 3 / 15 Salmani et al . : Assessing clinical reasoning in nursing students 132 Journal of Medical Education Development ¦ Volume 18 ¦ Issue 2 ¦ 2025 Figure 1. PRISMA 2020 flow diagram Tools/Instruments Finally, the quality of 25 articles was evaluated using assessment tools fitting the study design. The qualitative articles were assessed using the Critical Appraisal Skills Programme (CASP) tool for qualitative studies (10 items - Table 2). Interventional articles were evaluated using the CASP tool for clinical trial studies (11 items - Table 3), while mixed methods studies were assessed with the 5-item Mixed Methods Appraisal Tool (MMAT - Table 4). Descriptive articles were reviewed using the Joanna Briggs Institute (JBI) tool (8 items - Table 5), and nonclinical trials were assessed with the Minor tool (12 items - Table 6). Table 2. Quality qualitative studies First author, year Elenita Forsberg, 2015 [72] Carina Georg, 2018 [73] Clear aims? ✓ ✓ Qualitative methodology appropriate? ✓ ✓ Research design appropriate to address aims? ✗ ✓ Appropriate recruitment strategy? ✗ ✓ Data collection appropriate? ✗ ✗ Relationship between researcher and participants considered? ✗ ✗ Ethical issues considered? ✓ ✓ Data analysis sufficiently rigorous? ✗ ✗ Clear statement of findings? ✗ ✗ Valuable research? ✗ ✗ [ DOI: 10.61882/edcj.18.2.129 ] [ Downloaded from edujournal.zums.ac.ir on 2025-10-03 ] 4 / 15 Salmani et al . : Assessing clinical reasoning in nursing students Journal of Medical Education Development ¦ Volume 18 ¦ Issue 2 ¦ 2025 133 Table 3. Quality clinical trial studies First author, year Gouifrane et al., 2020 [52] Blanié et al.,2020 [41] Did the trial address a clear question? ✓ ✓ Was the assignment of patients to treatments randomised? ✗ ✓ Were all of the patients who entered the trial properly accounted for at its conclusion? ✓ ✓ Were patients, health workers, and study personnel ‘blind’ to treatment? ✗ ✓ Were the groups similar at the start of the trial? ✓ ✓ Aside from the experimental intervention, were the groups treated equally? ✗ ✗ How large was the treatment effect? ✓ ✓ How precise are the estimates of the treatment effect? ✗ ✓ Can the results be applied to the local population? ✓ ✓ Were all clinically important outcomes considered? ✓ ✓ Are the benefits worth the harms and costs? ✓ ✓ Table 4. Quality mixed method study First author, year Is there an adequate rationale for using a mixed methods design to address the research question? Are the different components of the study effectively integrated to answer the research question? Are the outputs of the integration of qualitative and quantitative components adequately interpreted? Are divergences and inconsistencies between quantitative and qualitative results adequately addressed? Do the different components of the study adhere to the quality criteria of each tradition of the methods involved? Cheng et al., 2024 [31] yes yes yes yes yes Johnston et al., 2019 [34] yes yes yes yes yes Table 5. Quality cross-sectional studies First author, year Was the study based on a random or pseudorandom sample? Were the criteria for inclusion in the sample clearly defined? Were confounding factors identified and strategies to deal with them stated? Were outcomes assessed using objective criteria? Were group descriptions sufficient in comparisons? Was follow up carried out over a sufficient time period Were the outcomes of people who withdrew described and included in the analysis Were outcomes measured in a reliable way Was appropriate statiscal analysis used Kuiper et al., 2009 [5] Yes No No No No No No Yes No Kuiper et al., 2008 [8] Yes Yes No No No No No Yes No Damodaran et al., 2023 [42] Yes Yes No Yes Yes Yes No Yes Yes Hong et al., 2021[32] Yes No No Yes Yes Yes Yes Yes Yes Khanyile et al., 2005 [67] Yes Yes Yes Yes Yes Yes No Yes No Koivisto et al., 2016[69] Yes No No Yes Yes Yes Yes Yes Yes Data analysis Based on the research team members' decision, articles accepted for final evaluation needed to achieve a score of at least 50% of the total possible points. Two researchers reviewed and rated all articles, sharing the results and reaching an agreement. A third rater resolved any disagreement between the two raters. [ DOI: 10.61882/edcj.18.2.129 ] [ Downloaded from edujournal.zums.ac.ir on 2025-10-03 ] 5 / 15 Salmani et al . : Assessing clinical reasoning in nursing students 134 Journal of Medical Education Development ¦ Volume 18 ¦ Issue 2 ¦ 2025 Results In the quality assessment, five articles did not meet the criteria for inclusion in the study, resulting in a final selection of 20 articles for analysis (Figure 1). The quality status of the methodology for these 20 approved studies is detailed in Tables 2 to 6. Table 6. Quality non randomized studies First author year Applicable in non-comparative studies Applicable in comparative studies) score Clearly stated aim Inclusion of consecutive patients Prospective collection of data Endpoints appropriate to the aim of the study Unbiased assessment of the study endpoint Follow-up period appropriate to the aim of the study Loss to follow-up less than 5% Prospective calculation of the study size Adequate control group Contemporar y groups Baseline equivalence of groups Adequate statistical analysis Son HK et al., 2023 [60] 2 2 2 2 2 2 2 2 Not applicable Not applicable Not applicable Not applicable 16/16 Marcomini et al., 2021 [35] 2 2 2 2 2 0 0 1 Not applicable Not applicable Not applicable Not applicable 11/16 Kautz et al., 2005 [64] 2 2 2 2 0 2 0 1 Not applicable Not applicable Not applicable Not applicable 11/16 Hosseini et al., 2021 [53] 1 2 2 2 0 0 2 1 Not applicable Not applicable Not applicable Not applicable 10/16 Arisudhana et al., 2022 [47] 2 2 2 2 0 2 2 2 2 2 2 2 22/24 Forneris et al., 2015 [48] 2 1 2 2 0 0 2 2 2 2 2 2 19/22 Arisudhana et al., 2022 [46] 2 2 2 2 0 2 2 2 2 2 2 2 22/24 Hu et al. 2021 [33] 2 2 2 2 0 2 2 2 2 2 2 2 22/24 Kim et al., 2015 [59] 2 2 2 2 0 2 2 2 2 2 2 2 22/24 Moghadam et al., 2019 [68] 2 0 2 2 0 2 2 2 2 2 2 2 20/24 Seo et al., 2021 [63] 2 2 2 2 0 2 2 2 2 2 2 2 22/24 de Sá Tinôco et al., 2021 [71] 2 2 2 2 0 0 0 2 2 2 2 2 18/24 Yauri et al., 2019 [70] 2 2 2 2 0 1 2 2 2 2 2 2 21/24 This review comprised 20 articles (Table 7), including 12 interventional studies, two clinical trial articles, four descriptive cross-sectional studies, and two mixedmethods articles. The findings revealed that five articles utilized the Nurses Clinical Reasoning Scale (NCRS) (25%), two articles employed Script Concordance Tests (SCTs) (10%), two articles applied the key feature test (10%), two articles used the Outcome-Present State Test (10%), two articles implemented rubrics (10%), two articles adopted the triple jump exercise (10%), one article used the Health Sciences Reasoning Test (HSRT) (5%), one article applied scenarios (5%), one article employed the Clinical Reasoning Assessment Tool (5%), and one article utilized a researcher-made questionnaire (5%). Additionally, the findings indicated that ten articles (47.61%) did not report the instruments' validity, while six articles did not indicate the reliability of the instruments. Moreover, no studies reported the qualitative assessment of nursing students' clinical reasoning. In addition, no study pointed to the acceptability, costs, or cost-effectiveness of clinical reasoning assessment tools. [ DOI: 10.61882/edcj.18.2.129 ] [ Downloaded from edujournal.zums.ac.ir on 2025-10-03 ] 6 / 15 Salmani et al . : Assessing clinical reasoning in nursing students Journal of Medical Education Development ¦ Volume 18 ¦ Issue 2 ¦ 2025 135 Table 7. A review of the studies conducted on clinical reasoning assessment tools Row Author(s), Year, Country Study design Clinical reasoning assessment tool Assessment objective Reliability & Validity 1 Blanié et al., 2020, France [41] Experimental Script Concordance Test (SCT) Compare simulation by gaming vs. traditional teaching for detecting patient deterioration Expert-confirmed reliability; Cronbach’s alpha = 0.75 2 Damodaran et al., 2023, India[42] Descriptive Script Concordance Test (SCT) Compare clinical reasoning between BSc and post-basic nursing students to inform curriculum strategies Reliability confirmed by 6 obstetricians, 3 nurses, and 15 midwives 3 Arisudhana, 2022, Indonesia[47] Quasiexperimental Clinical Reasoning Assessment Tool Effect of disease script training on nursing students’ clinical reasoning Expert-confirmed reliability = 0.72; Cronbach’s alpha = 0.82 4 Cheng et al., 2024, Taiwan [31] Mixed methods Nurses Clinical Reasoning Scale (NCRS) Effects of unfolding case studies on clinical reasoning and team collaboration Cronbach’s alpha = 0.98 5 Forneris et al., 2015, USA[48] Quasiexperimental Health Sciences Reasoning Test (HSRT) Replicate findings on increasing clinical reasoning through structured explanation Coefficient of reliability (Kuder-Richardson 20); Internal consistency = 0.77– 0.84; Validity confirmed in original study (Facione & Facione, 2006) 6 Gouifrane et al., 2020, Morocco [52] Experimental Key Feature Test Effect of blended learning in blood transfusion course on clinical reasoning Not reported 7 Hong et al., 2021, South Korea[32] Crosssectional Nurses Clinical Reasoning Scale (NCRS) Factors affecting students' clinical reasoning Cronbach’s alpha = 0.85 8 Hu et al., 2021, China [33] Quasiexperimental Nurses Clinical Reasoning Scale (NCRS) Impact of triage simulation training on students’ clinical reasoning Cronbach’s alpha = 0.937 9 Johnston et al., 2019, Australia [34] Mixed methods Nurses Clinical Reasoning Scale (NCRS) Impact of simulation debriefing on students’ perceptions of reasoning and learning transfer Cronbach’s alpha = 0.9 10 Kautz et al., 2005, USA[64] Quasiexperimental Outcome-Present State Test (OPT) Promote clinical reasoning via the OPT model Not reported 11 Hosseini et al., 2005, Iran [53] Quasiexperimental Key Feature Test Evaluate pharmacology simulation training on clinical reasoning Content validity confirmed by 10 subject-matter experts 12 Khanyile & Mfidi, 2005, S. Africa[67] Comparativedescriptive Triple Jump Exercise Compare PBL vs. traditional methods for developing clinical reasoning Internal consistency and inter-rater reliability confirmed; Content validity supported 13 Kim et al., 2015, South Korea[59] Quasiexperimental Rubric Effect of one-time simulation on reasoning, knowledge, and confidence Expert-confirmed reliability; Cronbach’s alpha = 0.70– 0.72 14 Koivisto et al., 2016, Finland[69] Crosssectional descriptive Researcher-made Questionnaire Explore student experience using 3D games for clinical reasoning Expert-confirmed reliability; Cronbach’s alpha = 0.647– 0.832 15 Marcomini et al., 2021, Italy[35] Quasiexperimental Nurses Clinical Reasoning Scale (NCRS) Effect of open case studies with game elements on reasoning Cronbach’s alpha = 0.92 16 Moghadam, 2019, Iran[68] Quasiexperimental Triple Jump Exercise Diagnose patients from scenarios and formulate nursing diagnoses Expert-confirmed reliability; Cronbach’s alpha = 0.87 17 Seo et al., 2021, South Korea[63] Quasiexperimental Outcome-Present State Test (OPT) Simulation-based training effects on reasoning, problem-solving, and competency Cronbach’s alpha = 0.88 18 Son HK, 2023, South Korea [60] Quasiexperimental Rubric Effect of simulation with PBL on reasoning and continuous assessment Cronbach’s alpha = 0.95 overall; Subscales: Noticing (0.89), Interpretation (0.80), Responding (0.89), Reflection (0.81) 19 Tinôco et al., 2021, Brazil [71] Quasiexperimental Clinical Case Solution Determine reasoning levels based on correct case responses Not reported 20 Yauri, 2019, Indonesia[70] Quasiexperimental Clinical Scenarios Improve clinical reasoning using contextualized guided learning Content validity confirmed by experts and student sample [ DOI: 10.61882/edcj.18.2.129 ] [ Downloaded from edujournal.zums.ac.ir on 2025-10-03 ] 7 / 15 Salmani et al . : Assessing clinical reasoning in nursing students 136 Journal of Medical Education Development ¦ Volume 18 ¦ Issue 2 ¦ 2025 Discussion In this section, 10 identified tools for assessing clinical reasoning are presented separately: The Nurses Clinical Reasoning Scale (NCRS) The review data indicated that the most frequently used clinical reasoning assessment tool was the NCRS. This scale, developed by Liou et al., is available in Chinese and consists of 15 items scored on a 5-point Likert scale. The total score ranges from 25 to 75, with higher scores reflecting a higher level of clinical reasoning. The content validity of this tool was confirmed with a Content Validity Index (CVI) of 1. The construct validity of the tool was examined through factor analysis, and 15 items were confirmed. The instrument's reliability was evaluated and confirmed with Cronbach's alpha coefficient of 0.7, an internal consistency coefficient of 0.7, and an Intraclass Correlation Coefficient (ICC) value of 0.85. It is worth noting that this instrument's interpretation of clinical reasoning is limited because it measures self-perceived competencies rather than proven practical competencies in clinical reasoning [30].This instrument was used in five studies conducted in Taiwan [31], Korea [32], China [33], Australia [34], and Italy [35]. The studies from Taiwan, Korea, and China only addressed the psychometric properties of the original version of the instrument, focusing solely on its reliability. The reported reliability values for these studies were 0.98 [30], 0.85 [32], and 0.93 [33], respectively. A study conducted in Australia only referred to the permission for the instrument and did not assess or report the validity and reliability of the scale [34]. Additionally, a study conducted in Italy did not report the scale's validity but assessed and confirmed its reliability, yielding Cronbach's alpha coefficient of 0.90 [35]. Since data collection is considered one of the most important stages in a research project, it requires reliable and valid instruments [1]. Thus, reliable results cannot be extracted from data collected with little precision. For this reason, data should be collected with valid instruments fitting the cultural context of the research population. However, if no such instrument exists, a valid and reliable instrument fitting the cultural context of the community in question should be translated and used [36]. Studies by Cheng [31], Hu [33], and Johnston [34] have highlighted the limitations of this tool, particularly concerning the self-reporting nature of students' clinical reasoning, which qualifies it as a subjective form of evaluation. Script Concordance Tests ) SCTs ( The second tool was script concordance tests, which are effective for assessing clinical reasoning. Based on script theory [37], these tests are developed based on cognitive psychology, which posits that healthcare providers organize, store, and access their knowledge through "disease scripts." These "scripts" allow the individual to use pattern recognition and previous clinical experience to make decisions during patient care [38]. SCTs evaluate students'students' clinical reasoning in conditions of uncertainty within complex situations [39]. It is important to note that SCTs do not analyze the students' problem-solving approaches but assess whether the outcomes align with expert opinions. This is where the unique value of using such tests to measure clinical reasoning skills lies. One strength of SCTs is that various media, including images, audio, and videos, can be incorporated into the scenarios, allowing them to closely replicate real-life situations. However, developing scenarios to measure clinical reasoning instead of knowledge is difficult. Moreover, it is also not easy to access experts who can score the responses [40]. The review data showed that two studies on nursing students used SCTs to assess clinical reasoning. Blanié et al. developed a script concordance test based on the frameworks of Charlin et al. and Forneris et al., which demonstrated confirmed validity; the reliability of the test was established with a Cronbach'sCronbach's alpha coefficient of 75% [41]. Regarding the limitations of the tool, Blanié notes that it requires prior training before use, and the reliance on self-reporting by students may diminish data reliability. In a study by Damodaran et al., the developed scenarios were given to a panel of experts to answer the items in the scenarios and confirm the validity of the scenarios [42]. It is important to note that SCTs should be evaluated by 10 to 20-panel members to enhance the accuracy of the test and ensure adequate reliability. For a reliable test, it is necessary to develop 25 scenarios and incorporate four items for each scenario [43]. Scholars believe that SCTs have good acceptance as a tool for measuring clinical reasoning because they reflect real clinical situations. Furthermore, training students about this type of test and re-administering it can help improve their understanding of script concordance tests [44]. Considering that a very limited number of studies have explored using SCTs in nursing, these assessments have not garnered significant attention in this field [45]. [ DOI: 10.61882/edcj.18.2.129 ] [ Downloaded from edujournal.zums.ac.ir on 2025-10-03 ] 8 / 15 Salmani et al . : Assessing clinical reasoning in nursing students Journal of Medical Education Development ¦ Volume 18 ¦ Issue 2 ¦ 2025 137 Clinical Reasoning Assessment Tool The next tool is the Clinical Reasoning Assessment Tool, developed by Arisudana and Puspawait in Indonesian. This tool consists of 36 items scored on a 3-point Likert scale, with total scores ranging from 25 to 75. The tool's reliability has been confirmed with Cronbach's alpha coefficient of 82%, while its specificity is reported at 65%, and its precision is estimated at 72%. Additionally, the tool's validity has been established [46]. However, in a study conducted in Indonesia, it was only utilized by its developers, Arisudana and Matini. This study identified a potential response bias from students as a limitation due to the self-report nature of the clinical reasoning assessment [47]. Health Sciences Reasoning Test (HSRT) The fourth tool is the HSRT. This tool was used by Forneris et al. in Minnesota. The HSRT is a multiplechoice test consisting of 33 items, featuring a variety of scenarios in clinical and professional contexts with information presented in both text and graphic formats. The items on this test require test takers to apply their skills to interpret information, analyze data, draw valid inferences, identify claims and reasons, and evaluate the quality of arguments. The tool's reliability has been established with a coefficient of reproducibility of 20, while its internal consistency is supported by Cronbach's alpha coefficient, which ranges from 0.77 to 0.84. A limitation of this tool is that it is not specifically designed for nursing or nursing students; rather, it aims to assess health professionals, which may limit its effectiveness in evaluating clinical reasoning in nursing students [48]. Key Feature The Key Feature Test is the fifth tool. It is a written or electronic test in which a short scenario containing key and non-key components is presented, and the candidate must make a clinical decision based on it. For example, the candidate might need to determine what key findings are necessary for diagnosis and what actions should be prioritized for the patient's clinical management. The responses to the items can be either brief answers or selections from a list [49]. To ensure that a key feature test possesses good face and content validity, the items should be developed based on a blueprint that clearly outlines the main focuses [50, 51]. The review data indicated that this tool has been utilized in two studies. Gouifrane et al. designed 30 key feature items based on the clinical case of blood transfusion, enabling students to identify relevant clues by linking information and searching for missing details, creating hypotheses and clinical judgments, and ultimately making effective clinical decisions with appropriate explanations. Gouifrane noted the limited ease of applying the tool in clinical settings [52]. Similarly, Hosseini et al. developed and employed 15 key feature questions to assess nursing students' clinical reasoning in a clinical pharmacology course [53]. Rubric The rubric is the sixth tool. A rubric is a coherent set of specific criteria describing the qualitative performance level [54]. It functions as a blueprint that outlines the mastery of a skill [55] and is regarded as a valid and reliable tool for instructors [56], provided that the developed rubric possesses strong validity [51]. Its validity should be evaluated and confirmed by experts, including nursing education experts, clinical instructors, and students as stakeholders [57]. Rubrics can facilitate the assessment of clinical reasoning in undergraduate students from their first year through their internship. They can also strengthen students' capacity for selfassessment so that they can develop effective thinking skills and provide instructors with the opportunity to monitor their improvement of clinical reasoning skills. Instructors can strengthen this skill in students by providing timely and effective feedback. Rubrics can be utilized in various educational contexts, including online courses, real-world settings, and clinical education [57, 58]. The data showed that two studies have used rubrics. Based on a literature review and expert opinions, Kim et al. designed a rubric that consisted of 4 sections: data collection, diagnosis, problem prioritization, and planning, and these sections were related to the steps of the nursing process. In this rubric, each step had a description of the student's performance and a score range, and the total student score ranged from 2 to 10. Thus, the instructor could obtain information about the student's clinical reasoning status. Kim et al. indicated that the validity of this method diminishes if only a single facilitator is used, making this a key limitation of the tool [59]. In their study, Son et al. used a rubric developed by Tanner. This rubric consisted of four sections: noticing (3 items about understanding the patient's condition and relevant information), interpreting (2 items about interpreting the patient's condition and relevant information), responding (3 items about establishing rapport with the patient), and giving feedback (2 items about reflecting on nursing practice). The rubric had 10 items with a total score ranging from 10 to 40 that [ DOI: 10.61882/edcj.18.2.129 ] [ Downloaded from edujournal.zums.ac.ir on 2025-10-03 ] 9 / 15