Developing Clinical Judgment in an Online Environment

By Susan Sportsman, PhD, RN, ANEF, FAAN

Perhaps the most critical challenge we face is to ensure that our graduates are competent when making clinical judgements appropriate for novice nurses. Developing this competence has always been important—after all, effective clinical judgment is what keeps the clients we serve safe. However, the implementation of the Next Generation NCLEX (NGN) by the National Council of State Boards of Nursing (NCSBN) in 2023 has brought this need into prominence. At the same time, the pandemic has created the need to deliver more instruction for nursing students in an online format. Let’s look at four principles to help us achieve the outcomes of developing novice nurses who make effective clinical judgment the core of their nursing practice, all of which can be implemented in an online setting.

1. 1. Emphasize a variety of active, problem-based learning activities, including case studies and case reviews. This principle is not new advice. For years, we have been talking about using case studies in classroom settings as part of active learning or “flipping the classroom.” The challenge to use in-class case studies has been our need (and the students’ desire) to be given content during class. As we have transitioned to online learning, the notion that students’ brains are “vessels that must be filled” seems ludicrous. Requiring students to review content before interacting with case studies in the online content seems more realistic.
   2. Require students to reflect on chosen solutions to clinical scenarios, identifying patterns which help them choose appropriate responses to client needs. A plethora of case studies are available to faculty, either those commercially published or those derived from the clinical experiences of faculty, that allow students to apply their clinical knowledge to a clinical situation online. I would also suggest that case review – evaluating the case when the results of the case are already documented—is also an effective way to teach clinical judgment. Reviewing the actions, reactions, and interactions, including potential rationales for what was done—or not done—can help students to develop skill in evaluation of the care they, and others, provide. This approach also allows students to experience the complexity of most clinical situations and recognize that often multiple approaches may be RIGHT actions that lead to a positive outcome.
   3. Require students to collaborate with colleagues. Yes, I know…students generally do not like to collaborate, particularly when some or all of the class is asynchronous. After all, they may be planning to do their work at 2 am! Despite this reluctance, best practice suggests that collaboration tends to stimulate diverse ideas, brainstorming, and consensus building (Sergent, Stajkovic,2020), all skills necessary for effective clinical judgment.
   4. Ask probing questions that require reflection throughout the lesson. I expect that all of you have had the experience of using the discussion board function on your learning management system to gauge students’ response to material. Often, to encourage students to respond, we give “points” for the number of times they post in a given period. If you are like me, you are often disappointed with the quality of the students’ work. Their responses often seem as if they are just posting to be posting, as a way to achieve the necessary points. One way to improve the quality of the posting–and the underlying reflection—is to spend the necessary time to craft the questions to guide the discussion toward analysis and synthesis of information. Probing questions require the respondent to look beyond “yes” or “no” and move from reaction to reflection. Here are some examples of probing questions:

• • • What do you think would happen if….?
    • How will you plan to…?
    • Why do you think this might happen?
    • What are some ways you can…?
    • Why did you decide to…?
    • How will you include…?
    • What is the value of ….?

Such probing questions provide structure for students to think deeply about their work. This approach also gives faculty direction to develop discussion grading rubrics.

A final note:

The ultimate student outcome is to develop effective clinical judgment skills. All health care providers make clinical judgments using automatic, intuitive reasoning, analytic reflective reasoning, or both.  As a result, health care providers might switch their judgment strategies based on the circumstances they find themselves, leading to potential errors in judgment (Cascella, 2020). These errors are a result of cognitive biases, systematic errors in thinking, including:

• • Anchoring bias: the tendency to rely too heaving on one piece of information—usually the first—when making decision.
  • Wishful thinking bias: when the decision-maker overestimates the rewards of an idea, while underestimating the risk, often because they are relying on what they want to be true.
  • Confirmation bias: the tendency to look for information that confirms their preconception, often dismissing information that may challenge them.
    (Becker Hospital Review, 2017)

Everyone is susceptible to these types of biases; however, a part of developing our students’ clinical judgment competencies is helping them reflect upon their decision-making in order to recognize the flaws in their thinking. Effective use of online education discussed above can help faculty address this issue.

 References

Cascella, L. (2020) Clinical judgement: What is it and how does it contribute to Diagnostic Errors? https://www.medpro.com/clinical-judgment-cah#:~:text=In%20outcome%20bias%2C%20for%20example,than%20what%20might%20realistically%20happen. Accessed, January 2021.

Sergent, K., Stajkovic, A. (2020) Women’s leadership is associated with fewer deaths during the COVID-19 crisis:  Qualitative and Qualitative Analysis of United States Governors. Journal of Applied Psychology. 105 (8) 771-78

_____ (2017) How four types of cognitive bias contribute to physician diagnostic errors—and how to overcome time.  Prevention & Education Center.  Becker Hospital Review. June 9^th.  https://www.beckershospitalreview.com/  Accessed, January 2021