Thinking Not Doing: How Changes Give Opportunity to Focus on Clinical Judgment

On clinical days, educators probably feel like the entire day is spent checking things off the to-do list. I recall having a spreadsheet with all the “duties” my students had to complete during clinical time and checking them off as they were done. Think about this—you have eight to ten students in your traditional six-hour clinical group. Each student will be completing the following “duties” in this time frame:

1. Complete morning general survey/safety check
2. Check vital signs
3. Prepare the patient for breakfast
4. Administer morning meds
5. Provide ADL care
6. Complete physical assessment
7. Administer IV meds
8. Complete additional procedures/skills such as dressing change, restart an IV, insert or remove a foley, administer an enema, check blood glucose, ambulate the patient
9. Administer any pre-lunch meds
10. Prepare patient for lunch
11. Give SBAR report to the nurse

That’s 88 – 110 things total your students must complete, and you must supervise or review! That leaves very little time for students to really think about their patient, and very little time for you to help them focus on clinical judgment.

According to the NCSBN, new graduates are lacking in these clinical judgment skills. Most educators would agree that there is no replacement for caring for a real patient to build that mindset, but the pandemic caused major changes to clinical experiences for nursing students. Despite the challenges, this is an opportunity for educators to spend more time helping students focus on the thinking related to caring for a patient instead of just hands-on skills.

With the use of Elsevier’s wealth of tools, you can have multiple “patients” for your students to care for. These include HESI Case Studies, SimChart Case Studies, and the Simulation Learning System (SLS) simulations. Create meaningful activities around these tools that will help build clinical judgment. Here are some examples:

HESI Case Studies

Have students review the pharmacology included in these cases and develop medication information guides, along with patient teaching information. They can utilize Elsevier’s robust database, Clinical Key, to find patient teaching guides and drug monographs to guide this activity. During your debriefing time, select students to roleplay the patient education session.

Ask students to develop a care plan or discharge teaching plan for the case study patient. Include debriefing sessions where you ask those clinical judgment questions such as:

• What is the priority nursing assessment for this patient?
• What is your priority intervention?
• What if this patient developed a complication?
• What therapeutic communication techniques would be appropriate for this patient and why?
• What nursing skills would you expect to perform on this patient and why? (you could then have them view the skill video for each and identify the unexpected outcomes of those skills and what to do if these happen)
• How would you evaluate if your care was effective? Labs, Assessments, etc.

SimChart Case Studies and SLS Simulations

Keep in mind with these cases, students have access to a fully developed EHR for each patient. Students can get a realistic experience of exploring the patient’s chart and identifying key information needed to plan care for the patient. Consider these activities:

• Have students review the Provider Charts (history and physical, orders, consultation notes, progress notes) and determine the three most important pieces of information needed to plan care for this patient.
• What safety risks does the patient exhibit?
• Review the provider orders and identify which ones you would implement first.
• Have them review the MAR and develop patient teaching guides for each medication.
• Provide students with the Patient Report for several patients and let them prioritize who they would see first and why.
• Have students review the Patient Reports and determine what could be delegated and the best patient assignment
• Have them complete an end-of-shift report during your synchronous sessions, passing the care of one patient on to another student.

As you can see from these examples, students will be focused on making nursing decisions about patient care, which will help build their clinical judgment skills.

Now your “checklist” can include things such as:

• Assign and supervise care of client provided by others (e.g., LPN/VN, assistive personnel, other RNs)
• Initiate, evaluate, and update client plan of care
• Provide and receive hands-off of care (report) on assigned clients
• Utilize resources to enhance client care (e.g., evidenced-based research, information technology, policies and procedures)
• Educate client on safety issues
• Use therapeutic communication techniques
• Evaluate client response to medication
• Evaluate appropriateness and accuracy of medication order for client
• Evaluate responses to procedures and treatments
• Perform focused assessments
• Educate client about treatments and procedures

This list could go on and on! You may recognize these points as Activity Statements from the RN Practice Analysis report from NCSBN, which provide details on content areas tested on the NCLEX. This makes an excellent resource as you adapt your classroom and prepare you students for clinical practice. Moving forward, take advantage of this opportunity to help students build clinical judgment in the online world!