Clinical teacher showing something on tablet to student
HealthOctober 27, 2020

Teaching clinical judgment through cases

By: Allen A. Cadavero Jr, PhD, RN, CCRN, WOCNMarilyn H. Oermann, PhD, RN, ANEF, FAAN
At all levels of nursing education, an important program outcome is for students to develop higher-level cognitive skills. The ability to analyze data, consider possible patient problems or diagnoses and think through and decide on the best approaches to use are critical skills not only for prelicensure students but also for learners preparing for advanced practice.

Providing safe care requires more than knowledge: students need to use their knowledge to interpret data, identify and prioritize patient problems and arrive at carefully thought-out decisions about the best actions to take in a clinical situation. These are skills that students need to develop in their nursing courses.

There has been extensive literature over the years describing the cognitive skills nurses use in their daily work caring for patients and making other decisions in clinical settings. Some studies have focused on problem-solving and decision making; others have explored critical thinking skills—the ability to think through a situation considering alternate perspectives and approaches to make an informed decision. More recently the complexity of nursing care has been studied from the framework of clinical judgment. Early on, Tanner (2006) described clinical judgment as including four aspects: (a) noticing (what is expected in a clinical situation, what is noticed first and what additional information should be collected; (b) interpreting (meaning of the data); (c) responding (possible interventions); and (d) reflecting on decisions and what could be done differently next time. In addition to Tanner’s model, other frameworks of nursing clinical judgment have also been described.

Recognizing that sound clinical judgment is critical for safe and effective patient care, the National Council of State Boards of Nursing (NCSBN) determined the need for assessing clinical judgment on the Next Generation NCLEX (NGN). The NCSBN (2019) defined clinical judgment as the “observed outcome of critical thinking and decision making” (p. 1). With this process, the nurse assesses patients and clinical situations, identifies, and prioritizes patient problems and concerns, consider potential solutions and implements evidence-based solutions, and evaluates outcomes.

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.

Scenario

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

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 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 Judg-ment 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 the thought process they 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.

Allen A. Cadavero Jr, PhD, RN, CCRN, WOCN
Assistant Professor, Duke University School of Nursing, Durham, North Carolina
Marilyn H. Oermann, PhD, RN, ANEF, FAAN
Thelma M. Ingles Professor of Nursing, Duke University School of Nursing, Editor-in-Chief, Nurse Educator , Durham, North Carolina
  1. National Council of State Boards of Nursing (NCSBN). (2019, winter). Next generation
  2. NCLEX news: Clinical Judgment Measurement Model. Chicago: NCSBN. Available at https://www.ncsbn.org/NGN_Winter19.pdf.
  3. Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment. Journal of Nursing Education, 45(6), 204-211. doi: 10.3928/01484834-20060601-04

Table 1. Questions as prompts to teach clinical judgment

Steps/phases of clinical judgment Sample questions as prompts
Recognizing cues

What findings are most significant?

What additional information is needed to decide what is wrong with this patient?

What data are relevant/not relevant?

What information should be collected first? As a priority in the assessment?

What findings need follow up?

What questions should the nurse ask (the patient, the family, others) in the assessment?

Analyzing cues

What patient problems/conditions/diagnoses are consistent with these findings?

What findings did you expect?

What additional information would help you better understand the significance of these findings?

Are there data of particular concern to you? Why?

Identifying possible problems/generating hypotheses

What are possible explanations of the patient’s condition? Explain your thinking.

Based on the information in the scenario, what are all possible problems the patient might have?

Considering possible problems of this patient, what is the priority? Why?

If the patient’s symptoms were X, how would that change your thinking about the patient’s condition?

Identifying interventions/generating solutions

Which outcomes are most important for this patient? In this situation?

What interventions are indicated?

What evidence supports each of these interventions?

In what ways will the interventions promote the expected outcomes of care?

Are there interventions to avoid? Which ones and why?

Implementing interventions/taking action

What interventions are most appropriate?

What interventions should be done first? Why?

What actions should be taken now?

What information would you teach the patient/caregiver prior to discharge?

What information, event, or situation should be reported immediately to the manager/health care team/other? Why?

Evaluating outcomes

What are important findings to monitor to determine if the patient is improving?

Is this patient improving? Why or why?

Are the interventions effective? If not, what other interventions and approaches should be considered?

What observations would you make or questions would you ask to assess if the patient/caregiver knows how to (perform the procedure, give oneself the treatment, follow the protocol)?

Adapted from National Council of State Boards of Nursing (NCSBN). (2019, winter). Next generation NCLEX news: Clinical Judgment Measurement Model. Chicago: NCSBN. https://www.ncsbn.org/NGN_Winter19.pdf; Hensel, D., & Billings, D.M. (2020). Strategies to teach the National Council of State Boards of Nursing Clinical Judgment Model. Nurse Educator, 45(3),128-132. doi: 10.1097/NNE.0000000000000773; Oermann, M. H., & Gaberson, K. B. (2021). Evaluation and testing in nursing education (6th ed.). New York, NY: Springer Publishing.


Table 2. Sample cases

A 55-year-old patient is admitted to your unit from the emergency department with dizziness and a severe headache with increasing severity. Her current vital signs are temperature 37.4 C, pulse 108 bpm, respirations 24 per minute, and blood pressure 189/106. In the handoff the nurse reports that the patient vomited about 30 minutes ago.

  1. What findings are most significant?
  2. What additional information is needed?
  3. What questions would you ask the nurse giving the handoff? Why is this information important?

Your ventilated patient has his bed elevated 45o. During his scheduled repositioning and turning, you notice redness on his sacrum. You also notice he keeps slipping down in the bed.

  1. What actions should be taken now?
  2. Your preceptor discusses the possibility of lowering the bed elevation to about 30o. Is this appropriate for his patient? Why or why not? What evidence supports your answer?
  3. If the bed elevation is lowered, what findings would you monitor to determine if this was the best intervention?

A mother brings her 1-month-old infant into the community clinic with reports of poor feeding. After completing your assessment, you notice the child whimpering without tears and that he weighs 6 lbs. 5 oz., the same as his birth weight.

  1. What patient problems/conditions/diagnoses are consistent with these findings?
  2. What other assessment finding would you expect?
  3. What additional information is needed to support your findings?
  4. What questions would you ask the mother?

A 19-year-old transgender male comes to the student health center requesting “the morning after pill.” While taking the patient’s vital signs, you notice bruises on the patient’s extremities and laceration in the inside his mouth.

  1. What questions should the nurse ask the patient in the assessment?
  2. What additional information is needed to decide what is wrong with this patient?
  3. What interventions should be done first? Why?
  4. What information would you teach the patient prior to discharge?

A 78-year-old client returns to the extended care facility after having an outpatient CT scan with contrast. The patient refuses dinner and is becoming more agitated. His evening vital signs are temperature 38.1 C, pulse 124 bpm, respirations 28 per min, and blood pressure 89/56. The nurse notices the patient has not voided since before his procedure early this morning.

  1. Are there data of particular concern to you? Why?
  2. Considering possible problems of this patient, what is the priority? Why?
  3. What patient problems/conditions/diagnoses are consistent with these findings?
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