Clinical Reasoning Evaluation Simulation Tool (CREST)

Thank you for your interest in using “Clinical Reasoning Evaluation Simulation Tool” (CREST).

This tool was developed by the research team led by:

Liaw Sok Ying, RN, PhD
Associate Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of
Singapore.
nurliaw@nus.edu.sg

You have been granted permission to use this developed tool which is designed specifically to measure clinical reasoning
skills in recognising and responding to clinical deterioration in a simulated environment. Please note that this tool has
been validated and tested. It should not be changed in any way. Attached is a copy of the instrument for you to use.

This tool has 10 items, scored with a five-point Likert rating scale, which are grouped into 8 subscales. These are either
rated based on questioning (items 1, 4, 5, 6, & 10) to elicit verbal responses or observations of a simulation performance
(items 2, 3, 7, 8, & 9). A final global item, scored with a 10-point Likert rating scale, allows rating of the nurse/nursing
student’s performance as a whole.
The following steps are recommended:
1. Reading time. The individual should be given some time (e.g. 5 minutes) to read the case notes of the simulated
scenario.
2. Questioning. The assessor rates item 1 through face-to-face questioning.
3. Simulation performance. The assessor rates items 2, 3, 7, 8, & 9 by observing the individual’s simulation performance
and use of the ‘think aloud’ strategy.
4. Questioning. The assessor rates items 4, 5, 6, & 10 through face-to-face questioning.

We have published an article on this tool:

Liaw SY, Rashasegaran A, Wong LF, Deneen CC, Cooper S, Levett-Jones T, Goh HS, Ignacio J. Development and
psychometric testing of a Clinical Reasoning Evaluation Simulation Tool (CREST) for assessing nursing students' abilities to
recognize and respond to clinical deterioration. Nurse Education Today. 2018 Mar 1;62:74-9.

Liaw SY, Rashasegaran A, Wong LF, Deneen CC, Cooper S, Levett-Jones T, Goh HS, Ignacio J. Development and psychometric testing of a
Clinical Reasoning Evaluation Simulation Tool (CREST) for assessing nursing students' abilities to recognize and respond to clinical
deterioration. Nurse education today. 2018 Mar 1;62:74-9.
 Domain/Item Questioning (Q)/ 1 2 3 4 5 Score
Observation(O)
Considering patient situation
1) Interpretation of Q : How have you Unable to interpret Limited attempt to Interprets case Interprets case Interprets case
patient's current interpreted the given relevant case interpret relevant case information to reveal information to reveal information thoroughly
situation from case information? information information some important most important patterns to reveal all important
information patterns or deviations or deviations patterns or subtle
deviations
Collecting cues
2) Performs physical O : Observe Unable to collect Collects a limited Collects important cues Collects important cues Collects important cues
assessment to gather performance of physical important cues relevant number of cues relevant relevant to the case with relevant to the case relevant to the case
cues assessment to the case to the case limited use of a using a systematic using a thorough
systematic approach approach systematic approach
Processing information
3) Recognizes and O : Observe through Unable to recognize Limited ability to Recognizes patient Recognizes patient Recognizes all patient
interprets patient “think aloud” on the obvious abnormalities recognize abnormalities abnormalities with abnormalities with some abnormalities with clear
abnormalities recognition and limited interpretation interpretation interpretation
interpretation of
abnormalities
4) Clusters cues Q : How do you link the Unable to make Limited ability to make Clusters main cues Clusters main cues Able to cluster main
together to identify signs and symptoms of connections between connections between together with limited together with sound cues together with
relationships among the patient together? cues cues reasoning reasoning thorough reasoning
them
Identifying problem/ issue
5) Identifies appropriate Q : What do you think Unable to identify Limited ability to Identifies appropriate Identifies appropriate Identifies appropriate
problem(s) with had happened to the appropriate problems identify appropriate problems with limited problems with sound problems with
reasoning patient? problems reasoning reasoning thorough reasoning
Establishing goals
6) States desired Q : What did you aim to Unable to identify Identifies limited desired Identifies desired Identifies desired Identifies desired
patient outcomes do for the patient and desired outcomes outcomes outcomes with limited outcomes with sound outcomes with thorough
why? reasoning reasoning reasoning
Domain/ Item Questioning (Q)/ 1 2 3 4 5
Observation(O)
Taking actions
7) Performs action(s) O : Observe actions Unable to perform Performs limited Performs appropriate Performs appropriate Performs appropriate
to achieve desired taken to manage appropriate actions appropriate actions actions with limited actions with actions with optimal
outcomes situation effectiveness effectiveness effectiveness and
efficiency
8) Communicates O : Observe Unable to communicate Limited ability to Communicates main Communicates main Communicates main
effectively to escalate communication skills via main issues communicate main issue issues with limited use issues clearly and issues clearly and
for help phone call of ISBAR concisely using ISBAR concisely using ISBAR
and with a sense of
urgency
Evaluating outcomes
Liaw SY, Rashasegaran A, Wong LF, Deneen CC, Cooper S, Levett-Jones T, Goh HS, Ignacio J. Development and psychometric testing of a Clinical Reasoning Evaluation Simulation Tool (CREST) for assessing
nursing students' abilities to recognize and respond to clinical deterioration. Nurse education today. 2018 Mar 1;62:74-9.
 9) Evaluates O : Observe actions Unable to evaluate Limited evaluation of Evaluates the Evaluates the Evaluates the
effectiveness of action taken to evaluate action outcomes action outcomes effectiveness of action effectiveness of action effectiveness of action
outcomes outcome and adjust with limited ability to with some ability to with clear ability to
interventions adjust action plans adjust action plans adjust action plans
Reflecting on process and new learning
10) Performs effective Q : What do you think Unable to reflect on Limited reflection on Reflects on strengths Reflects on strengths Reflect on strengths and
reflection for ongoing were your strengths and strengths and strengths and and weaknesses with and weaknesses with weaknesses with clear
improvement weaknesses ? Where do weaknesses weaknesses limited ability to identify some ability to identify ability to identify plans
you think you could plans for improvement plans for improvement for improvement
have done better?
11) Overall
On a scale of 1-10, rate the participants’ overall clinical reasoning skill
1 2 3 4 5 6 7 8 9 10
Unsatisfactory Outstanding
Total score:

Liaw SY, Rashasegaran A, Wong LF, Deneen CC, Cooper S, Levett-Jones T, Goh HS, Ignacio J. Development and psychometric testing of a Clinical Reasoning Evaluation Simulation Tool (CREST) for assessing
nursing students' abilities to recognize and respond to clinical deterioration. Nurse education today. 2018 Mar 1;62:74-9.