Clinical Simulation Evaluation Tool (CSET)

Abstract

The Clinical Simulation Evaluation Tool (CSET) is a behavioral rating scale designed to assess the performance of nursing and medical students during complex, high-fidelity simulated patient scenarios. Developed by Radhakrishnan, Roche, and Cunningham (2007), the CSET measures critical nursing clinical practice parameters, including safety protocols, basic assessment skills, prioritization, critical thinking, intervention planning, delegation, and communication. Its primary utility lies in evaluating the efficacy of training programs utilizing advanced patient simulators, such as the Human Patient Simulator (HPS), by scoring performance across five key domains in a simulated, two-patient assignment.

Keywords

Clinical Simulation Evaluation Tool, CSET, Human Patient Simulator, HPS, Nursing Education, Clinical Skills, Performance Assessment, Safety, Prioritization, Medical Simulation.

Authors

Kavita Radhakrishnan, Joan P. Roche, Helene Cunningham

Purpose

The primary purpose of the CSET is to provide a structured, objective method for scoring the performance of healthcare trainees, particularly nursing students, within a simulated clinical environment. It functions as an evaluation rubric used by clinical faculty to quantify observed behaviors and decision-making processes during complex, multi-patient scenarios, with a total possible score of 50 points.

The scale was explicitly developed to help address the lack of empirical evidence regarding the effectiveness of high-fidelity patient simulators in improving clinical competence. By standardizing the assessment of specific performance indicators—ranging from basic procedural safety (like hand hygiene and patient identification) to advanced critical thinking—the CSET facilitates targeted feedback and curriculum improvement in medical and nursing clinical practice education.

Construct

The CSET measures the overarching construct of clinical competence in a simulated environment. This competence is operationalized across five core performance domains, which together capture the necessary skills for safe and effective patient care in complex, high-pressure settings:

• Safety: Encompasses adherence to fundamental patient safety protocols, including hand hygiene, patient identification verification, allergy verification, and proactive error recognition.
• Basic Assessment Skills: Measures the systematic application of the ABCs (Airway, Breathing, Circulation), Level of Consciousness (LOC) assessment, and accurate monitoring of vital signs (VS) and pain levels.
• Prioritization and Critical Thinking: The ability to identify the priority patient and/or immediate problem, followed by accurate identification of actual and possible medical or nursing problems.
• Interventions and Evaluation: Focuses on the timely initiation of appropriate priority interventions (e.g., applying oxygen, administering critical medications) and subsequent reassessment of the patient’s status.
• Delegation and Communication: Assesses the ability to appropriately assign tasks to other personnel and effectively communicate critical patient information with healthcare providers (HCPs) using standardized frameworks like SBARR.

Validity

The initial validation study conducted by Radhakrishnan, Roche, & Cunningham (2007) provided preliminary evidence supporting the CSET’s ability to differentiate clinical performance based on training exposure. The study compared nursing students who received traditional clinical training supplemented by Human Patient Simulator (HPS) training versus those who received only traditional training.

The results demonstrated specific concurrent validity for certain items: the group receiving additional HPS training performed significantly better in two critical areas: ‘Verifies Patient Identification’ (Safety domain) and ‘Vital Signs/O2 Sat/Pain Assessment’ (Basic Assessment domain). This sensitivity suggests that the CSET is a viable measure for capturing improvements in specific clinical behaviors resulting from clinical simulation exposure.

Reliability

The authors stated that the psychometric properties of the CSET are discussed within the 2007 pilot study. However, detailed reliability statistics, such as specific coefficients for inter-rater reliability, test-retest reliability, or internal consistency (Cronbach’s Alpha) for the entire scale and its subdomains, were not provided in the source description. Establishing robust inter-rater reliability is crucial for performance evaluation tools like the CSET to ensure consistent scoring among clinical faculty observing complex, dynamic simulation scenarios.

Factor Analysis

Formal factor analysis results detailing the underlying dimensional structure of the CSET items were not explicitly provided in the source documentation. The scale is organized around five predefined clinical domains (Safety, Assessment, Prioritization, Interventions, Communication/Delegation), reflecting a theoretical framework derived from essential clinical competencies rather than an empirically derived structure through exploratory or confirmatory factor analysis.

Instrument

Test Type: Behavioral Observation Checklist / Performance Evaluation Rubric

Format: Criterion-referenced checklist with assigned weighted scores (total possible score of 50 points). Scores translate into an equivalent letter grade and a Clinical Evaluation Tool (CET) Behavior Rating.

Language Available: English (Original development language).

Population Group: Healthcare trainees (specifically nursing and medical students).

Age Group: Adult students enrolled in medical or nursing programs.

Population Details: Used primarily in educational settings involving high-fidelity patient simulation, often focusing on complex, multi-patient assignments.

Test Methodology: Direct observation by clinical faculty during a complex, live simulation scenario, typically using an advanced patient simulator (e.g., HPS).

Keywords

Clinical Competence, High-Fidelity Simulation, Nursing Skills, SBAR, Patient Safety, Assessment Skills, Critical Thinking, Evaluation Rubric, Psychometrics.

Authors

Author ORCID Identifier: Not available in source.

Affiliation Email addresses: Not available in source.

Correspondence Address: Not available in source.

Permissions & Fee and Test Year

Test Year: 2007 (based on initial publication).

Permissions and Fee: Information on commercial licensing or fee structure is not detailed in the source material. The tool originated from academic research published in the International Journal of Nursing Education Scholarship, suggesting it may be available for non-commercial educational research, though formal permission from the original authors or institution should be sought for implementation.

Reference’s

• Radhakrishnan, K., Roche, J. P., & Cunningham, H. (2007). Measuring clinical practice parameters with human patient simulation: A pilot study. International Journal of Nursing Education Scholarship, 4(1). Article 8.

Items of the Clinical Simulation Evaluation Tool (CSET)

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

Student:________________________Date: _______Evaluator:__________________ Clinical Faculty:_____________

Objectives	Possible Points	Observed Patient A CHF hypertension	Observed Patient B New Chest Pain	Actual Points
Safety
*Hand Hygiene: Performs proper hand hygiene before caring for each patient and as needed	*2 (1 each)	___ Hand wash*	___ Hand wash*
*Introduces Self: States name and role to patient, family member and/or helath care provider.	*2 (0.5 each)	___ Introduces Self* ___ Identifies Role *	___ Introduces Self* ___ Identifies Role*
*Verifies Patient Identification: Ask patient to state their name, DOB and verify on ID Band. OR verify patient name and Medical Record Number on ID band. Must look at ID band to receive points	*2 (0.5 each)	___ Verify Patient Full Name* ___ Verify Patient DOB*  OR ____Verify MR# *	___ Verify Patient Full Name* ___ Verify Patient DOB* OR ____Verify MR#*
*VerifiesAllergy: Asks the patient about allergies AND verifies correct allergy band.	*4  (1 each)	_____Ask  about allergies* _____Verify allergy band*	_____Ask  about allergies* _____Verify allergy band*
Communication: Explains to patient/and or family member what they are doing and/or why.	4   (1 each)	___ Explain Assessment ___ Explain Interventions	___ Explain Assessment ___ Explain Interventions
Error: Identifies medical error/s and states correction for error.	3 (1 each)	___ O2 off	___ Allergy Bracelet off ____Identify MD order route for Morphine wrong
Assessments and Critical Thinking
Identifies the Priority Patient	2	__Priority Patient to assess first when going in room initially because Airway
ABC’s & LOC:  Assesses Patient’s Airway (able to speak), Breathing (chest rising and falling), Circulation (check pulses) and Level of Conscious-ness (Should state out loud assessing these areas)	4 (0.5 each)	__ Airway __ Breathing (check) __ Circulation (check) __  LOC	__ Airway __ Breathing (check) __ Circulation (check) __  LOC
Vital Signs /O2 Sat/Pain: Assesses initial and previous VS/O2 Sat (don’t need to actually do, can check monitor) and Pain 0-10 (PQRSTU). Identifies pt’s normal and/or abnormal as a scenario evolves.	4 (0.5  each)	__ Temp, BP, HR, RR  ↑ __ O2 sat __ Pain 0-10 (PQRSTU) __ Identifies  changes	__ Temp, BP, HR, RR __ O2 sat __ Pain 0-10 (PQRSTU) __ Identifies changes
Focus Assessment: Assesses systems appropriately based on patient presentation, signs and symptoms.	5 (0.5 each)	___ LS Crackles ___ Pedal Edema ___ Dyspnea (ask about shortness of breath)	Chest Pain Assessment ____When it started? ____Location?    ____Radiation? _____Quality?      ____Pain Scale 0-10 ____Elevated ST segment____Oxy Sat lower
Problem Identification and  Critical Thinking
Identify Problem/s: Identifies actual and/or possible medical and/or nursing problems (Can identify while thinking out loud or by actions)	2 (0.5 each)	___ Potential fluid overload  600 in 200 out (in report) ___ Anxiety related to shortness of breath ___    ________________	___ Actual  MI ___ Allergy to shellfish – problem with order for Cardiac Cath with dye ___    _______________
Interventions, Evaluation & Critical Thinking
Priority Interventions: Initiates appropriate priority interventions in a timely manner for each patient.	8.5 (0.5 each)	___ Raise the HOB ___ Apply O2 ___ Reassure & support ___ Reassess VS as needed	___ Raise HOB                     ___ Apply O2 ____Get EKG                     ___ Give NTG ___ Assess VS before each NTG dose ___ Call MD After Call MD do or say what would do: ___Increase Oxygen (First unless delegating) ____Morphine (*with correct dose calculated- critical to pass) (Second) ___ ASA        ____Hang NS 40 mL ____Delegate blood work ____Cancel stress test ____ Reassess VS as needed
Delegates appropriate possible tasks to others.	2.5 (0.5 each)	___ Check O2 sat as follow-up ___ Provide care	___  EKG                ___  Blood work ____Cancel  Stress Test
Communicates with HCP in timely manner: Gives appropriate info using SBARR guidelines (see sheet near phone to call HCP if needed).	2 (0.5 each)		___ Situation     ___ Background ___ Assessment/ Recommendations ___ Read Back
Other Critical Thinking and Processing Components
Thinking Process: Discusses out loud during/after scenario possible problems, pathophysiology, and/or rationale for assessment and interventions.	1 (0.5 each)	_____Thinks out loud during scenario 1 _____________ 10 rarely               all times	_____Thinks out loud during scenario 1 _____________ 10 rarely               all times
Reflection: Identifies strengths and areas for improvement when viewing video with objectives and discussion with faculty and peers.	2  (0.5 each)	___Strengths ___Areas of Improvement	___Strengths ___Areas of Improvement
Final Actual Total Points: _____ Equivalent Letter Grade:  _____ Remediation and Redo Recommended: Yes    No Comments (write in colums to right):	50 possible total points

Grading Scale

Actual Points (out of possible 50)	Equivalent Letter Grade	CET Behavior Rating
46.5-50  (equivalent to 93-100)	A	4.0
45-46  (equivalent to 90-92)	A-	3.7
43.5-44.5  (equivalent to 87-89)	B+	3.3
41.5-43  (equivalent to 83-86)	B	3.0
40-41  (equivalent to 80-82)	B-	2.7
38.5-39.5  (equivalent to 77-79)	C+	2.3
36.5-38  (equivalent to 73-76)	C	2.0
36 or lower (equivalent to 72 or lower)	C- or lower	0 and scenario must be repeated