Seven tips for teaching clinical judgment through cases

There are many teaching strategies that are effective in developing students’ clinical judgment and other cognitive skills. These strategies include questions, simulation with debriefing, think-aloud activities, discussions, cases and unfolding cases, reflection, and clinical practice. For these strategies to be effective, students need to explore different perspectives and alternatives rather than the expectation that all students will arrive at one correct response or decision. The purpose of this article is to describe the use of cases for promoting students’ clinical judgment and other higher-level cognitive skills. Cases with open-ended questions are easy to develop and lead to discussions about different perspectives and alternatives—the key to promoting clinical judgment.

Using cases for teaching clinical judgment

Cases have two parts: a clinical scenario about a patient, a family, or another situation in clinical practice, followed by questions about the scenario. An individual case can be developed, or they can unfold, with new data added to the scenario leading into other possible decisions. Those types of case studies will be used on the NGN examination.

Scenarios

Scenarios should be realistic situations that nurses encounter in their practice, which require some higher-level thinking skills to analyze, manage the patient’s conditions and evaluate outcomes. The scenario might present information about a patient for the student to identify what is important in the situation (recognize cues) and additional data needed to decide on the patient’s problem. Or, the scenario might present multiple patient problems, and it is up to the student to prioritize them and decide on the best interventions in this particular scenario. When writing the scenario, you can include assessment findings, cues that the student should recognize in the situation, information from the health history that may or may not be significant and activities that must be addressed quickly. It is best to vary the settings (not all hospital-based) in the scenarios to better reflect the many places where patients receive care. As part of their decision making, students should consider the resources available in a clinical setting, length of time the nurse is with a patient in that setting and frequency of patient visits, among other factors. The scenario can be presented in written form or via a short video clip or other technology.

Questions

The second part of the case includes questions that are asked about the scenario. The questions serve as prompts for clinical judgment versus questions that might be asked about a case for assessing students' knowledge and understanding. The questions might focus on identifying cues in the scenario, determining additional data to collect, interpreting patient problems and concerns, and analyzing the situation from different perspectives. Other questions can be used as prompts for identifying possible interventions—not only the best intervention but other potential approaches that might also be appropriate. Questions can focus actions to take in a situation, both immediate and long term, and outcomes to suggest improvement in a patient’s condition. Table 1 provides sample questions that can be used as prompts to teach clinical judgment. Questions can be in any format, but for teaching purposes, open-ended questions encourage discussion about different perspectives and alternatives.

One of the goals of the questions is to make the student’s thinking visible and provide an opportunity for peers to share their own thinking about the case. The aim is learning and open discussion about how to interpret and manage a case, not for grading students’ responses. These discussions allow educators to provide feedback to students, offer alternate perspectives and role model how they would approach the situation and think through the case.

Sample cases for teaching clinical judgment

A few short cases are provided in Table 2 illustrates the use of cases for teaching clinical judgment and other cognitive skills. The scenarios can often be reused with different questions and can be expanded into an unfolding case.

Integrating clinical judgment cases in your courses

Cases can be done in class, online or in a post-conference. They can be completed individually and then discussed with other students and the teacher, or in small groups where peers critique each other’s responses and share interpretations. The key to using cases for teaching clinical judgment is the discussion among students and with the educator. Discussions also avoid the teacher having to read and provide feedback on individual student papers. Here are some tips for developing and using cases for teaching clinical judgment:

1. Decide on a framework for teaching clinical judgment in your nursing program; this same framework should be used across all courses in the curriculum. NCSBN’s Clinical Judgment Measurement Model is an assessment model, but this model can be used for teaching clinical judgment and developing cases. There are other models and frameworks of clinical judgment that also can be used.
2. Introduce students to your framework and the need for clinical judgment and other higher-level cognitive skills to provide safe and effective care. This should be done early in the curriculum.
3. Identify the step or phase in the clinical judgment process to be learned and then write the scenario for that step or phase. For example, if the goal is for students to analyze data and recognize cues, the scenario should provide multiple findings for students to decide what is pertinent or not and to identify where additional information might be needed.
4. Use the questions as prompts for clinical judgment. The questions can be written as seen in the examples, or the teacher can ask students these questions. Table 1 provided some sample questions for this purpose, but these can be modified.
5. As you discuss cases with students, encourage multiple perspectives and answers as long as there is a rationale to support them. The goal is not to identify only one correct answer but to explore other possibilities.
6. Have students share their thought process used to analyze the scenario and answer the questions, then follow with how you would think through the situation.
7. Prepare students for these discussions at the beginning of your nursing program and course, and make it clear these are for learning not grading. Ensure a safe environment for students to share their thinking.

Summary

In clinical practice, nurses are faced with patients and other problems to be solved. Most often these are not clear cut nor are the solutions and actions to take. The ability to figure out what is wrong with the patient and the best approaches to use requires clinical judgment. Many nurse educators use cases, unfolding cases and longer case studies to help students apply concepts and other knowledge to clinical examples. Those cases can be geared to teaching clinical judgment: this article provided strategies for using cases to meet this outcome of learning.