Content area
Background
Nursing internship students often lack the necessary clinical decision-making skills, confidence, and experience due to limited competence. To ensure safe and high-quality care, nursing faculty must train graduates with the self-efficacy required to make effective decisions in complex, dynamic, and high-stress healthcare environments. The handover process involves the information that plays a critical role in clinical decision-making and care planning. One of the frameworks used in handover process is ISBAR (Identification, Situation, Background, Assessment, Recommendation). The clinical supervision model serves as an educational and supportive approach aimed at enhancing self-efficacy and skills, including the use of handover.
Objective
This study aimed to investigate the impact of an ISBAR-based Clinical Supervision Model (CSM) during handover on clinical decision-making and self-efficacy in nursing internship students.
Method
This quasi-experimental, two-group (pre-test and post-test) study was conducted in selected hospitals affiliated with Isfahan University of Medical Sciences, Iran, in 2024. Participants were selected through convenience sampling and then randomly allocated to either the intervention or control group. Data were collected using the ISBAR communication checklist, the Self-Efficacy in Clinical Performance (SECP) questionnaire, the Clinical Decision-Making questionnaire, and the Manchester Clinical Supervision Scale (MCSS). The clinical supervision model and routine supervision were administered over six sessions for the intervention and control groups, respectively. Data were analyzed using SPSS version 16. Independent t-tests and chi-square tests were used to assess baseline differences between groups. Paired t-tests evaluated within-group changes in clinical self-efficacy and clinical decision-making scores. ANCOVA was applied to compare ISBAR communication scores across six time points and post-intervention clinical self-efficacy and decision-making scores, controlling for pre-intervention values. Repeated measures ANOVA assessed within-group changes in mean ISBAR scores over time, while MANOVA examined multiple, interrelated ISBAR subscale scores. A significance level of p < 0.05 was set for all analyses.
Results
There were no significant differences in baseline characteristics between the intervention and control groups (p > 0.05). According to the within-group analysis, changes in the ISBAR communication scores over time were significant in both the intervention and control groups (p Time < 0.001), with a greater increase observed in the intervention group (p Intervention < 0.001). The intervention group demonstrated a significant improvement in clinical decision-making (p < 0.001) compared to the control group. Clinical self-efficacy showed significant improvement in both the control and intervention groups after the intervention (P < 0.05). However, between-group analysis showed that the increase was higher in the intervention group than in the control group (P < 0.001).) The mean score of the Manchester questionnaire in the intervention group in this study was 130.30, reflecting the high impact of implementing the clinical supervision model.
Conclusion
The findings revealed that the use of the clinical supervision model based on the ISBAR framework led to improvements in clinical self-efficacy and clinical decision-making, alongside the enhancement of handover skills in nursing internship students. Therefore, it is recommended that this model be utilized in the education of nursing students and newly graduated nurses to ensure safe and high-quality care.
Introduction
The internship program in Isfahan, Iran, has been launched since 2018. As part of the program, nursing students in their final year undergo clinical training across multiple hospital departments, working approximately 20 shifts per month, including morning, evening, and night shifts [1]. Throughout this program, students acquire hands-on experience in actual clinical settings and perceive themselves as integral members of the healthcare team, actively involved in patient care [2]. However, studies show that nursing internship students often lack the necessary clinical decision-making skills, confidence, and experience due to their limited competence. This raises concerns regarding the preparedness of newly graduated nurses [3, 4].
Newly graduated nurses, due to low self-efficacy, are unable to demonstrate appropriate clinical decision-making skills, highlighting the need to strengthen their self-efficacy so they can reason effectively, efficiently, and productively in complex, constantly changing, and high-stress healthcare environments [5]. Existing internship programs have a minimal effect on fostering the critical thinking abilities essential for clinical decision-making. Enhancing the structure and delivery of these programs could lead to better outcomes [6].
Self-efficacy is an individual’s belief in their ability to complete a task or achieve a goal, as well as the strength of that belief [7]. It plays a significant and positive role in educational outcomes and clinical performance competence for students in the future [8, 9]. Students with high self-efficacy are less vulnerable to stress and burnout, are highly adaptable to learning challenges, and consequently, are more successful [10, 11]. In healthcare environments, where there is a strong emphasis on error reduction, self-efficacy is critical for nurses [12]. Low self-efficacy leads to difficulties in recognizing acute patient conditions, delays in intervention, and a negative impact on patient care [13].
Given the 24-hour presence of nurses at the patient’s bedside, they are often the first healthcare providers to observe a sudden change in a patient’s situation, and their decisions can impact the patient’s life or death [14]. Clinical decision-making is a process in which healthcare providers collect, interpret, and assess data to select the most appropriate evidence-based action [15], and it is crucial for delivering safe, effective, and high-quality patient care [16, 17]. For nursing students with limited knowledge and experience, clinical decision-making is recognized as a complex process, and it requires education to enhance it, preparing them for safe and high-quality care in complex healthcare environments [17, 18–19].
Handover is the process of efficiently transferring clinical information to delegate professional responsibility and accountability for patient care to another individual or professional group [20]. Healthcare providers, including nurses and nursing internship students, use handover information for clinical decision-making and the development of patient care plans [21]. Inconsistent information during handover, with insufficient and non-specific details, leads to inappropriate decision-making that may be misaligned with the patient’s needs, thereby threatening patient safety and the quality of care [22].
The standardized framework Identification, Situation, Background, Assessment, Recommendation (ISBAR), endorsed by the World Health Organization (WHO), is proposed to facilitate intra- and inter-professional communication within healthcare teams across a wide range of clinical situations [23]. The use of the ISBAR framework can enhance the quality of handover and improve patient safety [24]. Due to its simple format and ease of memorization, while still encompassing essential information, ISBAR is commonly used by nurses in handover and communication processes [25]. Despite ISBAR being proven as a valuable tool for handover, effective training and practice for successful implementation are essential for nursing students [26]. The Clinical Supervision Model (CSM) is a clinical education approach developed to close the gap between theoretical knowledge and practical application [27]. Clinical supervision aims to provide professional support and promote learning to ensure safe healthcare practices [28].
Within the CSM, nurses and nursing internships are mentored by a qualified supervisor who provides feedback on their clinical performance [29]. This model encourages reflection on actions and decisions that could pose risks to patient safety [30]. The benefits of CSM include increased knowledge, reduced stress and burnout, improved job satisfaction, and enhanced self-awareness. Additionally, the CSM fosters confidence and self-esteem through support and encouragement, while also providing an opportunity to critically assess clinical practices in a safe environment [31]. The CSM impacts students’ independence [32] and is associated with effectiveness and improved quality of care [33]. Education and support aimed at improving self-efficacy and clinical decision-making are key factors in enhancing the quality and safety of patient care. Therefore, this study aimed to examine the impact of an ISBAR-Based CSM during handover on clinical decision-making and self-efficacy among nursing internship students.
Methods
Study design and setting
This quasi-experimental, two-group study with a pre-test and post-test design was conducted in the selected hospitals affiliated with Isfahan University of Medical Sciences, Iran, in 2024.
Participants
The nursing internship students who were completing the adult health nursing course in the medical and surgical departments of hospitals affiliated with Isfahan University of Medical Sciences were recruited. Inclusion criteria were: no prior participation in a handover training program and willingness to participate in the study. Exclusion criteria included unwillingness to continue participation in the study and withdrawal from the program.
Sample size
The sample size was calculated based on a similar study [34], considering values of S1 = 7.72, S2 = 4.49, µ1 = 75.31, µ2 = 65.51, α = 0.05, and β = 0.2. With an expected dropout rate of 15%, the estimated sample size was 80 participants. Initially, 80 out of 90 nursing internship students who met the inclusion criteria were selected using convenience sampling. The participants were subsequently assigned to either the intervention or control group using random allocation software [35]. Each group (intervention and control) comprised 40 participants (see Fig. 1: CONSORT diagram).
[See PDF for image]
Fig. 1
Consort flowchart
Study tools
Data were collected using a demographic questionnaire, ISBAR Communication Checklist, Self-Efficacy in Clinical Performance (SECP) questionnaire, Clinical Decision-Making questionnaire and Manchester Clinical Supervision Scale (MCSS).
Demographic characteristics questionnaire
This included questions about age, gender, and marital status.
ISBAR communication checklist
This scale was developed by WHO to assess nurses’ performance in applying the standard ISBAR framework during handovers [36]. It consists of 12 items rated on a 3-point Likert scale (0 = not implemented, 1 = incomplete, 2 = acceptable), with a total score range from 0 to 24. The validity and reliability of the Persian version were confirmed by Ghaesari et al. (2024). The Content Validity Index (CVI), Content Validity Ratio (CVR), and face validity were 1, 1, and above 1.5, respectively. External reliability was assessed using the test-retest method, with an intraclass correlation coefficient (ICC) of 0.803 (95% CI: 0.628–0.901, p < 0.001). Internal reliability, measured by Cronbach’s alpha, was 0.739 [37].
Self-efficacy in clinical performance (SECP) questionnaire
This questionnaire contains 37 questions in four domains: patient assessment, nursing diagnoses and planning, implementation of care plans, and evaluation. It uses a 5-point Likert scale (1 = not confident at all to 5 = completely confident), with total scores ranging from 37 to 185. This tool was developed by Cheraghi et al. (2009) in Iran, and its validity and reliability were confirmed [38].
Clinical decision-making questionnaire
This is the short version of the original 56-item scale developed by Lurie and Salantera (2002) [39]. It includes 24 questions covering four stages of the decision-making process: data collection, data processing and problem identification, care planning, implementation, and evaluation. The scale uses a 5-point Likert scale (0 = never or almost never to 1 = almost always or always), with total scores ranging from 24 to 120. Scores indicate three levels: analytic-systematic (≤ 67), analytic-intuitive (68–78), and intuitive-interpretive (≥ 79), reflecting a continuum from linear, problem-focused reasoning to more experience-based, integrative decision-making [40]. The validity and reliability of the Persian version were confirmed by Noohi et al. (2012) [41].
Manchester clinical supervision scale (MCSS)
This scale was developed in 1995 at the University of Manchester, UK [42] and is used to assess the effectiveness of the clinical supervision model. The scale comprises 32 items divided into 7 subscales: Trust and rapport, supervisor’s advice and support, improved care and skills, the importance and value of clinical supervision, finding time, personal issues, and reflection. Each item is rated on a 5-point Likert scale: Strongly disagree (1), Disagree (2), Neutral (3), Agree (4), and Strongly agree (5). Scores are summed within subscales. The Persian version of the questionnaire’s validity and reliability were confirmed by Khani et al. (2009), and the effectiveness score was recorded as 122 or higher [43].
Procedure
The researchers obtained informed consent from the participants after explaining the objectives of the study. Before the intervention, the clinical self-efficacy and clinical decision-making questionnaires were completed through self-report by participants in both groups. Also, the ISBAR communication score was calculated by observing the handover performance of participants in both the intervention and control groups.
Intervention group
In the intervention group, the ISBAR-based handover was introduced as a component of the Clinical Supervision Model, which comprised three stages [37, 44, 45]:
Phase 1
The researchers held an in-person meeting for the nursing internship students. During this meeting, the key elements of effective handover were discussed. Also, the researchers provided an explanation about the clinical supervision model, the roles of supervisors and students, and answered students’ questions. The ISBAR-based handover checklist was then provided to the students, and the items on the checklist were explained. The students were asked to apply the framework to two presented clinical cases, and any issues were addressed. At the end of the meeting, the participants were reminded to bring the checklist to future supervision sessions and use it to perform handovers accordingly.
Phase 2
One week after the previous stage, two supervisors attended the relevant departments to conduct clinical supervision sessions. These sessions were held when the nursing internship student had completed their shift and was in the process of handing over the patient to the incoming nurse at the patient’s bedside. In this study, two experienced nursing mentors in supervision and teaching were selected as the supervisors, as they were qualified to provide feedback and conduct handover. Before starting the study, inter-rater reliability between the supervisors, who simultaneously rated the handover of 30 participants using the ISBAR communication checklist, was assessed through the Intraclass Correlation Coefficient (ICC). The ICC value obtained was 0.881 (95% CI: [0.752, 0.943]), indicating excellent consistency between the raters.
These supervision sessions took place over a 3-month period [29], with a total of 6 sessions (two morning shifts, two evening shifts, and two night shifts per participant) [46], spaced two weeks apart [47]. During each session, students brought the ISBAR checklist and acted in accordance with its items. If they made any errors according to the checklist, the supervisor provided feedback, and the students discussed their challenges with the supervisor. In each session, the ISBAR communication score for the students was calculated according to the checklist. The duration of each clinical supervision session ranged from 40 to 60 min, and the sessions were conducted individually.
Phase 3
In this phase, the Manchester questionnaire was employed to assess the effectiveness of implementing the clinical supervision model.
Control group
A meeting was also arranged for the control group. During this meeting, the study’s objectives and the number of supervision sessions were discussed. It was mentioned that during the supervision sessions, their handover performance would be evaluated using the ISBAR communication checklist, but no checklist was provided to them [37, 44, 45]. In this group, 6 supervision sessions were held at two-week intervals over a period of 3 months. During these sessions, the ISBAR communication score for the nursing internship students was assessed and recorded by the supervisor at the patient’s bedside using the checklist. No feedback was provided regarding incorrect handover performance; however, if the students had any questions related to handover, they were answered.
At the end of the study, the clinical self-efficacy and clinical decision-making scores of both the intervention and control groups were obtained through self-report by the nursing internship students.
Data analysis
Data were analyzed using SPSS version 16 (SPSS, Inc., Chicago, IL, USA). Descriptive statistics (frequency, percentage, mean, and standard deviation) were used to summarize the data. The normality of continuous variables was assessed using the Kolmogorov-Smirnov test. To compare categorical variables between the two groups, the Chi-square test was used. For comparing mean scores between groups and within groups, independent t-tests, paired t-tests, analysis of covariance (ANCOVA), multivariate analysis of variance (MANOVA), and LSD test were applied. Additionally, to compare mean scores at six different time points, repeated measures analysis of variance (ANOVA) was performed. A significance level of p < 0.05 was considered statistically significant.
Results
There was no significant difference between the intervention and control groups in terms of demographic characteristics (p > 0.05) [Table 1]. The independent t-test indicated that there was no significant difference between the two groups in the baseline ISBAR Communication scores (p = 0.202). Repeated measures analysis revealed that although the mean ISBAR scores changed significantly over time in both the intervention and control groups (p Time < 0.001), the trend of these changes showed a significant difference between the two groups, with a greater increase in the intervention group (p < 0.001), based on the P value– Intervention and P value– Interaction. Analysis of covariance (ANCOVA) was used to compare the two groups across the six time points, considering the pre-intervention ISBAR scores as a covariate. The results indicated that the mean ISBAR scores differed significantly between the two groups at all successive measurements (p < 0.001) [Table 2]. Additionally, a pairwise comparison of the ISBAR Communication scores for the intervention group’s sessions using the LSD test showed a significant increase in scores for each supervision session compared to the other sessions (p < 0.001).
Table 1. The baseline characteristics in the intervention and control groups
Variable | Intervention group | Control group | t/χ2 | P Value a | |
|---|---|---|---|---|---|
Mean ± SD/N (%) | Mean ± SD/N (%) | ||||
Gender | Male | 20(50%) | 19(47.5%) | 0.050 | 0.823 |
Female | 20(50%) | 21(52.5%) | |||
Marital status | Single | 37(92.5%) | 35(87.5%) | 0.556 | 0.456 |
Married | 3(7.5%) | 5(12.5%) | |||
Age (Year) | 23.35 ± 1.67 | 23.38 ± 1.53 | 0.070 | 0.945 | |
ISBAR Communication score before intervention | 6.68 ± 3.39 | 7.55 ± 2.65 | 1.286 | 0.202 | |
clinical self-efficacy score before intervention | 91.55 ± 17.51 | 92.88 ± 16.94 | 0.344 | 0.732 | |
clinical decision-making score before intervention | 73.05 ± 15.66 | 75.48 ± 16.56 | 0.673 | 0.503 | |
The significance level is p ≤ 0.05
Data presented as Mean ± SD or n (%), SD: Standard Division, aP values are based on the independent sample t- test or chi square
Table 2. ISBAR communication score a of interventions and control group during clinical supervision sessions
Session | Intervention group | Control group | t/f | P Value b |
|---|---|---|---|---|
Mean ± SD | Mean ± SD | |||
Before Intervention | 6.68 ± 3.39 | 7.55 ± 2.65 | 1.286 | 0.202 |
First | 13.53 ± 4.36 | 8.23 ± 2.64 | 63.660 | < 0.001 |
Second | 15.95 ± 3.40 | 8.15 ± 2.68 | 238.862 | < 0.001 |
Third | 18.63 ± 3.02 | 8.28 ± 1.91 | 542.740 | < 0.001 |
Forth | 20.40 ± 2.45 | 8.80 ± 2.59 | 793.925 | < 0.001 |
Fifth | 21.28 ± 2.55 | 8.95 ± 2.88 | 682.219 | < 0.001 |
Sixth | 22.85 ± 1.37 | 9.23 ± 2.80 | 1164.254 | < 0.001 |
P value–Time c | < 0.001 | < 0.001 | ||
P value– Interaction c | < 0.001 | |||
P value– Intervention c | < 0.001 | |||
The significance level is p ≤ 0.05, and statistically significant results are bolded
a Maximum possible score = 24, b Independent sample t-test or Analyze of Covariance (ANCOVA), c Repeated measure ANOVA
The results of the ISBAR communication subscales showed that there was a significant difference between the intervention and control groups in all subscales (p < 0.001) [Table 3]. The independent t-test indicated that there was no significant difference between the two groups in terms of baseline clinical self-efficacy scores (p = 0.732). The analysis of covariance (ANCOVA) showed that the mean clinical self-efficacy scores in the intervention group at the end of the intervention, considering the pre-intervention clinical self-efficacy scores as a covariate, were significantly higher (p < 0.001). The paired t-test revealed that the mean scores of the intervention group before and after the clinical supervision sessions were significantly different (p < 0.001). Furthermore, the change in mean scores in the control group before and after the intervention was also statistically significant (p = 0.003), but the mean scores of the intervention group were higher than those of the control group [Table 4].
Table 3. Sixth session ISBAR communication score of interventions and control group: subscales and total score
Variable | subscales | Possible score range | Intervention group | Control group | DF a | F | P Value b | Ef c |
|---|---|---|---|---|---|---|---|---|
Mean ± SD | Mean ± SD | |||||||
Sixth session ISBAR Communication | Identification | 0–4 | 4.00 ± 0.00 | 1.65 ± 0.70 | 1 | 451.052 | < 0.001 | 0.853 |
Situation | 0–2 | 1.98 ± 0.16 | 1.23 ± 0.62 | 1 | 55.016 | < 0.001 | 0.414 | |
Background | 0–6 | 5.60 ± 0.55 | 1.83 ± 1.11 | 1 | 374.416 | < 0.001 | 0.828 | |
Assessment | 0–10 | 9.45 ± 0.99 | 3.98 ± 1.61 | 1 | 336.720 | < 0.001 | 0.812 | |
Recommendation | 0–2 | 1.83 ± 0.38 | 0.55 ± 0.55 | 1 | 143.478 | < 0.001 | 0.648 | |
Total score | 0–24 | 22.85 ± 1.37 | 9.23 ± 2.80 | 1 | 1164.254 | < 0.001 | 0.938 |
The significance level is p ≤ 0.05, and statistically significant results are bolded
a Degrees of Freedom, b Multivariate Analysis of Variance (MANOVA), c Effect size
Table 4. Difference in pre-post clinical self-efficacy score a between the intervention and control groups
Group | Before intervention | After intervention | P Value b |
|---|---|---|---|
Mean ± SD | Mean ± SD | ||
Intervention group | 91.55 ± 17.51 | 136.63 ± 10.86 | < 0.001 |
Control group | 92.88 ± 16.94 | 98.30 ± 12.63 | 0.003 |
P Value c | 0.732 | < 0.001 | |
t/f | 0.344 | 579.975 |
The significance level is p ≤ 0.05, and statistically significant results are bolded
a Maximum possible score = 185, b Paired sample t-test, c Independent sample t-test or Analyze of Covariance (ANCOVA)
The independent t-test indicated that there was no significant difference between the two groups in terms of baseline clinical decision-making scores (p = 0.503). The analysis of covariance (ANCOVA) revealed that the mean clinical decision-making scores in the intervention group at the end of the intervention, considering the pre-intervention clinical decision-making scores as a covariate, were significantly higher (p < 0.001). The paired t-test showed that the mean scores of the intervention group before (73.05 ± 15.66) and after (102.73 ± 8.75) the clinical supervision sessions were significantly different (p < 0.001), whereas the mean scores in the control group before (75.48 ± 16.56) and after (77.60 ± 13.53) the intervention did not differ significantly (p = 0.096) [Table 5]. The mean total score of the Manchester scale was 130.30, indicating the excellent effectiveness of CSM from the perspective of nursing internship students [Table 6].
Table 5. Difference in pre-post clinical decision-making score a between the intervention and control groups
Group | Before intervention | After intervention | P Value b |
|---|---|---|---|
Mean ± SD | Mean ± SD | ||
Intervention group | 73.05 ± 15.66 | 102.73 ± 8.75 | < 0.001 |
Control group | 75.48 ± 16.56 | 77.60 ± 13.53 | 0.096 |
P Value c | 0.503 | < 0.001 | |
t/f | 0.673 | 405.174 |
The significance level is p ≤ 0.05, and statistically significant results are bolded
a Maximum possible score = 120, b Paired sample t-test, c Independent sample t-test or Analyze of Covariance (ANCOVA)
Table 6. Manchester clinical supervision scale: subscales and total score
Subscale | Possible score range | Actual score range | Mean ± SD a |
|---|---|---|---|
Trust and rapport | 6–30 | 17–30 | 22.93 ± 3.69 |
Supervisor advice and support | 5–25 | 18–25 | 22.25 ± 2.05 |
Improved care and skill | 7–35 | 26–35 | 29.88 ± 2.20 |
Importance and value | 4–20 | 12–20 | 17.40 ± 2.31 |
Finding time | 4–20 | 7–20 | 14.33 ± 3.13 |
Personal issues | 3–15 | 7–12 | 9.68 ± 1.19 |
Reflection | 3–15 | 11–15 | 13.85 ± 1.14 |
Total score | 32–160 | 115–152 | 130.30 ± 8.61 |
a Standard Deviation
Discussion
This study aimed to assess the impact of an ISBAR-Based Clinical Supervision Model (CSM) during handover among nursing internship students, to enhance clinical decision-making and clinical self-efficacy. The results of the present study demonstrated that the ISBAR framework-based clinical supervision model improved clinical decision-making skills and clinical self-efficacy, which are critical components of nursing performance and clinical competence, in nursing internship students.
In the first phase of the CSM, an ISBAR framework-based handover checklist was provided to participants as a foundation for assess and feedback during clinical supervision sessions. Utilizing a structured approach such as ISBAR in the clinical decision-making process can be highly beneficial for students, helping to reduce stress and enhance their cognitive performance [48]. Moreover, this approach increases the likelihood of novice members’ participation in decision-making in high-stress situations [49].
In the second phase of the CSM, clinical supervision sessions were conducted at the end of the work shift when the nursing internship student was handing over the patient to the next shift nurse. The study by Dewi et al. (2021) indicated a strong positive correlation between nurses’ critical thinking abilities and clinical decision-making skills with the quality of handover, as nurses often need to analyze, interpret, and explain patient-related information during handover [50]. They are also required to provide suggestions and solutions regarding patient problems and make decisions to enhance the quality of nursing care [51]. During the intervention, the supervisor identified each student’s specific challenges in the handover process and, following feedback and discussion about deficiencies, developed plans to address them. Effective supervision creates opportunities for supervisees to recognize their strengths and skill gaps while offering necessary support for improvement. This reduces anxiety in supervisees, fosters a better perception of their performance, abilities, and skill levels, and positively impacts their self-efficacy [52]. In this phase, students participated in six clinical supervision sessions over three months, spaced two weeks apart, practicing patient handovers using the ISBAR framework for patients with various conditions and receiving repeated feedback. Continuous clinical supervision is essential for establishing a positive relationship between the supervisor and the student, contributing to clinical practice success [53]. Regular and ongoing practice is vital for mastering handover skills, including data collection, meaningful interpretation of assessments, clinical judgments [54], and improving clinical self-efficacy [55].
In the third phase of the CSM, the Manchester Clinical Supervision Scale (MCSS) was used to evaluate the model and its effectiveness. The MCSS scores indicated the high effectiveness of clinical supervision. Similarly, a systematic review (2022) showed that participation in clinical supervision, as measured by the MCSS, was associated with positive outcomes. Clinical supervision is most impactful when the professional development of the supervisee is the primary focus, and the supervisor possesses the necessary skills and attributes to foster constructive supervisory relationships [56].
In the intervention group, after implementing the CSM, the mean ISBAR Communication scores showed an upward trend over time, and the students’ skill performance in adopting the ISBAR framework for handovers improved significantly. Using the ISBAR framework in handover can ensure the effective transfer of information among nurses, thereby supporting continuity of care and preventing adverse events [57]. Scores across all five categories (Identification, Situation, Background, Assessment, Recommendation) increased significantly following the implementation of the clinical supervision model in the clinical setting. These results align with the study by Uhm et al. [2019], conducted with senior nursing students using the ISBAR framework and feedback in real clinical environments [55]. However, the study by Yu and Kang (2017), which employed role-play simulation to teach ISBAR-based handover in the intervention group, found no significant difference in the “Assessment” category scores between groups. Thus, merely increasing knowledge of the ISBAR framework may not suffice to enhance handover skills. Handover require the ability to accurately assess patient conditions, effectively interpret them, and present meaningful content [51].
In our study, the consistent presence of an experienced supervisor alongside the students over three months and their provision of feedback to address individual deficiencies effectively improved all ISBAR components. The study by Jolstad et al. (2017) emphasized the importance of clinical supervision for developing non-technical skills such as interpersonal, professional, and communication skills, as well as patient safety competencies among nursing students [58]. Similarly, the study by Ikbal et al. (2019) demonstrated that clinical supervision improved nurses’ knowledge, attitudes, and skill performance [59].
The results also demonstrated that the CSM, by enhancing the handover performance of nursing internship students, promoted their clinical decision-making skills from the analytic-intuitive level to the intuitive-interpretive level. This progression reflects a shift toward more advanced, experience-based clinical decision-making [40]. In this regard, the results of a study by Mohammadi et al. (2019) showed that implementing clinical supervision improved the level of clinical decision-making of nursing students [32]. Similarly, Etemadifar et al. (2020), in a study on intensive care unit nurses, observed improvements in clinical decision-making after participating in a program based on the ISBAR technique. Nurses reported greater confidence in their decisions when using the ISBAR technique [60]. Moreover, Farzaneh et al. (2023) demonstrated that an ISBAR-based educational program could enhance clinical self-efficacy and clinical decision-making skills in anesthesia nursing students, which is consistent with the findings of this study. The framework ISBAR facilitates rapid organization and prioritization of patient information, enabling interpretation of outcomes and improving clinical judgment through reflection on clues or anticipated results in patient scenarios [34]. Also, there is limited evidence regarding the transfer of learning related to clinical decision-making from simulation-based training to clinical practice among students [61]. However, in the CSM, students’ decision-making abilities are actively challenged in the clinical environment.
In our study, the mean clinical self-efficacy score significantly differed between the two groups, aligning with the findings of Lohani and Sharma (2023), who demonstrated that clinical supervision positively impacts the self-awareness and self-efficacy of psychotherapists and counselors [52]. However, the study by Uhm et al. (2019), which applied ISBAR based on experiential learning theory, reported no statistically significant difference in clinical practice self-efficacy scores between groups after the intervention. It suggested that to enhance nursing students’ clinical self-efficacy, a robust supportive environment for clinical practice and repeated training must be provided [55]. Clinical supervision supports the supervisee by allowing time to share concerns about their practice, instilling confidence, and fostering a sense of value, thereby reducing stress and burnout [30]. In our study, participants received frequent and individualized feedback on their performance. Similarly, Choi et al. (2023) emphasized that handover training for nursing students and nurses should include individualized feedback and opportunities for practice to improve their performance and self-efficacy [62].
The ISBAR-based clinical supervision model provides a structured approach for faculty and clinical supervisors to support nursing students during internships through observation, guided practice, and feedback. It can be adopted by other universities and teaching hospitals to strengthen students’ clinical competencies and bridge the gap between theory and practice. However, successful implementation may require preparatory training for supervisors, institutional support, and adequate time allocation for supervision. Challenges may include limited staffing, varying levels of faculty engagement, and the need to adapt the model to local clinical workflows and resources.
Conclusions
The ISBAR framework helps organize and prioritize patient information, interpret results, and develop care plans during handover. The CSM, in addition to offering emotional support and enhancing self-efficacy, provides nursing internship students with opportunities to identify challenges in handover, acquire knowledge, and practice extensively in a flexible manner. Implementing the CSM during handover with the ISBAR framework can reduce the complexity and anxiety associated with clinical decision-making for nursing internship. Therefore, the ISBAR-based CSM serves as an effective educational intervention to improve handover competency, clinical decision-making, and clinical self-efficacy in nursing students, ultimately enhancing patient safety and care quality.
Limitations
This study had certain limitations. One such limitation was the regular supervision of both the control and intervention groups by other faculty members for the purpose of scoring their internship credits. Moreover, students were not consistently present in the medical and surgical wards for three months, as they were required to complete rotations in the Intensive Care Units (ICU) and Cardiac Care Units (CCU), while the Clinical Supervision Model (CSM) depends on continuous supervision. However, these limitations were largely addressed through random allocation and the inclusion of a control group. Another potential limitation is that the supervisors were not blinded to group assignments, which may have introduced observer bias during the assessment of nursing handover skills. However, we attempted to minimize this risk by providing thorough training to the supervisors and using a structured, validated checklist to guide their evaluations.
Acknowledgements
The researchers would like to express their gratitude to the Vice Chancellor for Research of Isfahan University of Medical Sciences for the financial support of this study (project number: 2402293) and all participants.
Author contributions
FGH, SF, and MJT designed the study. FGH, FN, SAF and TMGh collected the study data. MJT, FGH, RTR and FN performed data analysis and interpretation. FGH and SF prepared the manuscript, and all authors read and approved the final manuscript.
Funding
This study was financed by the Vice Chancellor for Research of Isfahan University of Medical Sciences (Project number 2402293).
Data availability
The data supporting the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Committee of Isfahan University of Medical Sciences (IR.MUI.NUREMA.REC.1402.192). This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. All participants were informed about the study’s objectives and were assured that their personal information would remain confidential, participation was voluntary, and they could withdraw from the study at any time. All participants signed an informed consent form to participate in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
1. Shahzeydi, A; Taleghani, F; Moghimian, M; Farzi, S; Yazdannik, A; Farzi, K. Exploring nursing faculty, managers, newly graduated nurses, and students’ experiences of nursing internship program implementation in iran: a descriptive qualitative study. BMC Nurs; 2022; 21,
2. Nematollahi, M; Bagherian, B; Mehdipour-Rabori, R; Farokhzadian, J; Khoshnood, Z; Navidi, Z. Implementing the internship educational method, a step to reduce the gap between theory and practice, experience of undergraduate nursing students: A qualitative content analysis study. J Qualitative Res Health Sci; 2022; 11, pp. 253-9. [DOI: https://dx.doi.org/10.34172/jqr202214]
3. Wu, M. Theories behind a nursing intern’s error in terms of clinical decision-making. Front Nurs; 2020; 7,
4. Shen W, Zhu L, Lu Y. Factors Influencing Clinical Decision-making of Nursing Interns.579– 85. https://doi.org/10.26855/ijcemr.2023.10.010
5. Guerrero, J. A systematic review of the clinical Decision-Making skills in undergraduate nursing students. Ann Nurs Pract; 2019; 6,
6. Sarkoohi, Z; Nematollahi, M; Dehghan, M; Mehdipour-Rabori, R; Khoshnood, Z; Parandeh-Afshar, P et al. Can internship programs affect nursing students’ critical thinking disposition, caring behaviors, and professional commitment?. BMC Nurs; 2024; 23,
7. Croy, G; Garvey, L; Willetts, G; Wheelahan, J; Hood, K. Anxiety, flipped approach and self-efficacy: exploring nursing student outcomes. Nurse Educ Today; 2020; 93, 104534. [DOI: https://dx.doi.org/10.1016/j.nedt.2020.104534]
8. Yu, M; Tong, H; Li, S; Wu, XV; Hong, J; Wang, W. Clinical competence and its association with self-efficacy and clinical learning environments among Chinese undergraduate nursing students. Nurse Educ Pract; 2021; 53, 103055. [DOI: https://dx.doi.org/10.1016/j.nepr.2021.103055]
9. Haririan, H; Rahmani, A; Porter, JE; Heidarzadeh, M; Azadi, A; Faghani, S et al. Nursing students’ attitude and preparedness for nurse prescribing and its relationship with self-efficacy. Nurse Educ Pract; 2021; 54, 103126. [DOI: https://dx.doi.org/10.1016/j.nepr.2021.103126]
10. Bulfone, G; Fida, R; Ghezzi, V; Macale, L; Sili, A; Alvaro, R et al. Nursing student Self-efficacy in psychomotor skills: findings from a validation, longitudinal, and correlational study. Nurse Educ; 2016; 41,
11. Bulfone, G; Iovino, P; Mazzotta, R; Sebastian, M; Macale, L; Sili, A et al. Self-efficacy, burnout and academic success in nursing students: A counterfactual mediation analysis. J Adv Nurs; 2022; 78,
12. Stump, GS; Husman, J; Brem, SK. The nursing student Self-Efficacy scale: development using item response theory. Nurs Res; 2012; 61,
13. Takashiki R, Komatsu J, Nowicki M, Moritoki Y, Okazaki M, Ohshima S, et al. Improving performance and self-efficacy of novice nurses using hybrid simulation-based mastery learning. Jpn J Nurs Sci. 2022;e12519. https://doi.org/10.1111/jjns.12519
14. Lee, DS; Abdullah, KL; Subramanian, P; Bachmann, RT; Ong, SL. An integrated review of the correlation between critical thinking ability and clinical decision-making in nursing. J Clin Nurs; 2017; 26,
15. Marques, FM; Pinheiro, MJ; Alves, PV. Clinical judgment and decision-making of the undergraduate nursing students. Cien Saude Colet; 2022; 27,
16. Jans, C; Bogossian, F; Andersen, P; Levett-Jones, T. Examining the impact of virtual reality on clinical decision making - An integrative review. Nurse Educ Today; 2023; 125, 105767. [DOI: https://dx.doi.org/10.1016/j.nedt.2023.105767]
17. Akça, K; Berşe, S. Nursing students’ self-efficacy and clinical decision-making in the context of medication administration to children: A descriptive-correlational study. Nurse Educ Pract; 2023; 72, 103775. [DOI: https://dx.doi.org/10.1016/j.nepr.2023.103775]
18. Ahn, YH; Choi, J. Factors affecting Korean nursing student empowerment in clinical practice. Nurse Educ Today; 2015; 35,
19. Bucknall, TK; Forbes, H; Phillips, NM; Hewitt, NA; Cooper, S; Bogossian, F. An analysis of nursing students’ decision-making in teams during simulations of acute patient deterioration. J Adv Nurs; 2016; 72,
20. Brown-Deveaux, D; Kaplan, S; Gabbe, L; Mansfield, L. Transformational leadership Meets innovative strategy: how nurse leaders and clinical nurses redesigned bedside handover to improve nursing practice. Nurse Lead; 2022; 20,
21. Seada, AM; Bayoumy, SA. Effectiveness of handoff educational program on nurses interns’ knowledge, and communication competence. Am J Nurs Sci; 2017; 6, pp. 467-77. [DOI: https://dx.doi.org/10.11648/j.ajns.20170606.14]
22. Spooner, AJ; Chaboyer, W; Corley, A; Hammond, N; Fraser, JF. Understanding current intensive care unit nursing handover practices. Int J Nurs Pract; 2013; 19,
23. Moore, M; Roberts, C; Newbury, J; Crossley, J. Am I getting an accurate picture: a tool to assess clinical handover in remote settings?. BMC Med Educ; 2017; 17,
24. Mannix, T; Parry, Y; Roderick, A. Improving clinical handover in a paediatric ward: implications for nursing management. J Nurs Manag; 2017; 25,
25. Fahim Yegane, SA; Shahrami, A; Hatamabadi, HR; Hosseini-Zijoud, SM. Clinical information transfer between EMS staff and emergency medicine assistants during handover of trauma patients. Prehosp Disaster Med; 2017; 32,
26. Burgess, A; van Diggele, C; Roberts, C; Mellis, C. Teaching clinical handover with ISBAR. BMC Med Educ; 2020; 20,
27. Crafoord, MT; Fagerdahl, AM. Clinical supervision in perioperative nursing education in Sweden - A questionnaire study. Nurse Educ Pract; 2017; 24, pp. 29-33. [DOI: https://dx.doi.org/10.1016/j.nepr.2017.03.006]
28. O’Donnell, C; Markey, K; Murphy, L; Turner, J; Doody, O. Cultivating support during COVID-19 through clinical supervision: A discussion Article. Nurs Open; 2023; 10,
29. Gonge, H; Buus, N. Is it possible to strengthen psychiatric nursing staff’s clinical supervision? RCT of a meta-supervision intervention. J Adv Nurs; 2015; 71,
30. Markey, K; Murphy, L; O’Donnell, C; Turner, J; Doody, O. Clinical supervision: A panacea for missed care. J Nurs Manag; 2020; 28,
31. Bifarin, O; Stonehouse, D. Clinical supervision: an important part of every nurse’s practice. Br J Nurs; 2017; 26,
32. Mohammadi, F; Nikan, A; Movasagh, F; Paymard, A; Mirzaee, MS. The effect of clinical supervision on clinical decision. Int J Pharm Res; 2019; 11, pp. 1761-5. [DOI: https://dx.doi.org/10.31838/ijpr/2019.11.01.130]
33. Snowdon, DA; Leggat, SG; Taylor, NF. Does clinical supervision of healthcare professionals improve effectiveness of care and patient experience? A systematic review. BMC Health Serv Res; 2017; 17,
34. Farzaneh, M; Saidkhani, V; Ahmadi Angali, K; Albooghobeish, M. Effectiveness of the SBAR-Based training program in self-efficacy and clinical decision-making of undergraduate anesthesiology nursing students: a quasi-experimental study. BMC Nurs; 2023; 22,
35. Saghaei, M. Random allocation software for parallel group randomized trials. BMC Med Res Methodol; 2004; [DOI: https://dx.doi.org/10.1186/1471-2288-4-26]
36. World Health Organisation (W.H.O.). Patient safety curriculum guide: multi professional [2011:[Available from: http://apps.who.int/iris/bitstream/
37. Gheisari, F; Farzi, S; Tarrahi, MJ; Momeni-Ghaleghasemi, T. The effect of clinical supervision model on nurses’ self-efficacy and communication skills in the handover process of medical and surgical wards: an experimental study. BMC Nurs; 2024; 23,
38. Cheraghi, F; Hassani, P; Yaghmaei, F; Alavi-Majed, H. Developing a valid and reliable Self-Efficacy in clinical performance scale. Int Nurs Rev; 2009; 56,
39. Lauri, S; Salanterä, S. Developing an instrument to measure and describe clinical decision making in different nursing fields. J Prof Nurs; 2002; 18,
40. Phillips BC. Clinical decision making in last semester senior baccalaureate nursing students. The University of Wisconsin-Milwaukee; 2015.
41. Noohi, E; Karimi-Noghondar, M; Haghdoost, A. Survey of critical thinking and clinical decision making in nursing student of Kerman university. Iran J Nurs Midwifery Res; 2012; 17,
42. Winstanley, J. Manchester clinical supervision scale. Nurs Stand; 2000; 14,
43. Khani, A; Jaafarpour, M; Jamshidbeigi, Y. Translating and validating the Iranian version of the Manchester clinical supervision scale (MCSS). J Clin Diagn Res; 2009; 3,
44. Shahzeydi, A; Farzi, S; Tarrahi, MJ; Sabouhi, F; Babaei, S; Yazdannik, A. The effect of the clinical supervision model on nursing internship students’ nursing process-based performance: an experimental study. BMC Nurs; 2024; 23,
45. Shahzeydi, A; Farzi, S; Tarrahi, MJ; Babaei, S. The effect of clinical supervision model on nursing interns medication safety competence and knowledge: a clinical trial. Nurs Midwifery Stud; 2023; 12,
46. Edwards, D; Cooper, L; Burnard, P; Hannigan, B; Juggesur, T; Adams, J et al. Factors influencing the effectiveness of clinical supervision. J Psychiatr Ment Health Nurs; 2005; 12,
47. Dawson, M; Phillips, B; Leggat, SG. Effective clinical supervision for regional allied health professionals - the supervisee’s perspective. Aust Health Rev; 2012; 36,
48. McGregor, CA; Paton, C; Thomson, C; Chandratilake, M; Scott, H. Preparing medical students for clinical decision making: a pilot study exploring how students make decisions and the perceived impact of a clinical decision making teaching intervention. Med Teach; 2012; 34,
49. Hearns, S. Checklists in emergency medicine. Emerg Med J; 2018; 35,
50. Dewi NA, Yetti K, Nuraini T. Nurses’ critical thinking and clinical decision-making abilities are correlated with the quality of nursing handover. Enfermería Clínica. 2021;31. https://doi.org/10.1016/j.enfcli.2020.09.014. S271-S5.
51. Yu, M; Kang, KJ. Effectiveness of a role-play simulation program involving the Sbar technique: A quasi-experimental study. Nurse Educ Today; 2017; 53, pp. 41-7. [DOI: https://dx.doi.org/10.1016/j.nedt.2017.04.002]
52. Lohani, G; Sharma, P. Effect of clinical supervision on self-awareness and self-efficacy of psychotherapists and counselors: A systematic review. Psychol Serv; 2023; 20,
53. Bourke-Matas, E; Maloney, S; Jepson, M; Bowles, K. Evidence-based practice conversations with clinical supervisors during paramedic placements: an exploratory study of students’ perceptions. J Contemp Med Educ; 2020; 10,
54. Jeong, JH; Kim, EJ. Development and evaluation of an SBAR-based fall simulation program for nursing students. Asian Nurs Res (Korean Soc Nurs Sci); 2020; 14,
55. Uhm, JY; Ko, Y; Kim, S. Implementation of an SBAR communication program based on experiential learning theory in a pediatric nursing practicum: A quasi-experimental study. Nurse Educ Today; 2019; 80, pp. 78-84. [DOI: https://dx.doi.org/10.1016/j.nedt.2019.05.034]
56. Anggeria, E; Damanik, DW. Effective clinical supervision in nursing: systematic review. Open Access Macedonian J Med Sci; 2022; 10,
57. Hou, YH; Lu, LJ; Lee, PH; Chang, IC. Positive impacts of electronic hand-off systems designs on nurses’ communication effectiveness. J Nurs Manag; 2019; 27,
58. Jølstad AL, Røsnæs EER, Lyberg AM, Severinsson E. Clinical supervision and non-technical professional development skills in the context of patient safety-the views of nurse specialist students. 2017:253–67https://doi.org/10.4236/ojn.2017.72021
59. Ikbal, RN; Arif, Y; THE INFLUENCE OF IMPLEMENTATION OF THE CLINICAL SUPERVISION TEAM TO MONITOR THE PERFORMANCE OF, THE EMPLOYEES IN THE HOSPITAL ROOM OF X PADANG 2015. Malaysian J Nurs (MJN); 2019; 10,
60. Etemadifar, S; Sedighi, Z; Masoudi, R; Sedehi, M. Evaluation of the effect of SBAR-based patient safety training program on nurses’ clinical decision-making in the intensive care unit. J Clin Nurs Midwifery; 2020; 9, pp. 651-9.
61. Lavoie, P; Lapierre, A; Maheu-Cadotte, MA; Fontaine, G; Khetir, I; Bélisle, M. Transfer of clinical Decision-Making-Related learning outcomes following Simulation-Based education in nursing and medicine: A scoping review. Acad Med; 2022; 97,
62. Choi, JY; Byun, M; Kim, EJ. Educational interventions for improving nursing shift handovers: A systematic review. Nurse Educ Pract; 2024; 74, 103846. [DOI: https://dx.doi.org/10.1016/j.nepr.2023.103846]
© The Author(s) 2025. This work is published under http://creativecommons.org/licenses/by-nc-nd/4.0/ (the “License”). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.