Integrating Clinical Judgment Across Your Pre-Licensure Nursing Curriculum

Hillary Gamblin:

Hello. Thank you for joining today’s workshop on Integrating Clinical Judgment across your Pre-Licensure Nursing Curriculum. My name is Hillary Gamblin, I’m a GoReact employee. And today I’ll be chatting with three faculty members from the University of Kansas School of Nursing. We have Jessica Gay, Dr. Laura Klenke-Borgmann, and then Dr. Christina Phillips. Starting with Christina, and then moving to Jessica and Laura, would you three like to introduce yourselves real quick?

Christina Phillips:

Thank you Hillary. I’m Chris Phillips. Again, we’re faculty from the University of Kansas School of Nursing. We’re located in Kansas City, Kansas. We teach in a traditional pre-licensure curriculum so we have our students have two years of prerequisites before they come to us at our Academic Medical Center, where they do a two year, four semester nursing program. We have a concept-based curriculum and a competency-based clinical. All three of us are faculty in the first semester of the program, and I specifically teach the pharmacology portion for the students.

Jessica Gay:

Hi, my name is Jessica Gay. I’m also from University of Kansas, and I teach the Fundamentals Nursing course in the first semester in the fall each year for beginning students. So same semester as Chris is teaching pharm, I’m teaching them fundamentals. There’s only one section and so we have all of the same students that we teach at the same time. Here at KU, we have a campus in Kansas City where our medical center is where we have 115 students that are in the room with us during class each time. And then we also have a satellite campus in rural Kansas, in Salina, where there are 24 students who participate in class via live stream. So that just kind of tells you what we’re doing here. Laura.

Laura Klenke-Borgmann:

Alright. Good morning everyone. I teach the Pathophysiology course in the same semester that the Pharmacology course and the Fundamentals course are being offered as well. And what we’re going to be describing here today for you is a program of clinical judgment integration across our three courses in the students first semester in our program.

Hillary Gamblin:

Fantastic. Thank you for all three of you joining us. We like to tackle the most pressing issues in nursing education. So when we saw that you recently presented at NLN about clinical judgment, we knew we had to reach out and see if you could share your findings and we’re so grateful that you agreed.

Hillary Gamblin:

And for those of you who are new to our GoReact workshops, let me kind of quickly explain how we’ve structured these virtual events. For the first 30 minutes or so I’m going to be asking questions and talking with this lovely trio about their brilliant ideas for integrating clinical judgment across their curriculum. And then after that, we’ll do a live Q and A, and that’s about 10 to 15 minutes if we have enough time. And if you’d like to submit a question for the Q and A, there is a tab just below the video feed. And if you see a question someone else asked and you also want that answered, there is a handy up vote feature so you can vote for questions. Don’t forget the chat feature, which is located on the right side of the video feed. A lot happens here. People are sharing where they’re from, saying hello, sharing resources, getting information so they can stay in contact after the workshop. So don’t miss out.

Hillary Gamblin:

And then right next to the ask a question is a polling feature, and we actually like to start off today with a quick poll to get to know everybody better. And the question is, what challenges have you faced integrating clinical judgment development into your program? A, I don’t know enough about it. B, I don’t know where to start. C, I’m not convinced change is necessary. And then D, I don’t feel supported to make a change. So we’ll give you a second to answer that polling question and we’ll see the results.

Hillary Gamblin:

Okay. So as things are coming in, about 60% is, “I don’t know where to start.” Fantastic. This is the perfect workshop for you. So by the end of this workshop, we’re hoping these three will show and demonstrate applications of an in-class simulation program that develops clinical judgment. So ultimately we’re hoping that you can take these strategies and find ways to apply them in your own courses and overall nursing program curriculum. So this is right where you need to be.

Hillary Gamblin:

So let’s get started. First, I’m actually curious about how this whole presentation came about for NLN. What led you three to dedicate so much of your time and effort to clinical judgment?

Laura Klenke-Borgmann:

Great, thanks Hillary. So I actually became very interested and passionate about clinical judgment development several years ago as I watched my own students do well in didactic courses, and then continue to struggle to apply that knowledge to the bedside in the real world. So I started to ask myself and think about, “There has to be something that I can do as their nurse educator to help them bridge that classroom to clinical gap.” And so for my dissertation study for my PhD, I actually studied the effect of in class simulation experiences for student clinical judgment development. So really looking at does the use of this kind of innovative classroom strategy, bringing clinical into the classroom, help contextualize students knowledge acquisition and bridge that gap and make that a more seamless gap for them, between learning and knowledge acquisition and then actually applying it and seeing how it actually looks in the real world.

Laura Klenke-Borgmann:

The three of us, Chris and Jessica and I, work really closely together at the KU School of Nursing. We share a hallway, and we have lots and lots of hallway conversations. And I talked these two’s ear off about the importance of clinical judgment development for our students, and so we actually decided to collaborate and take what I learned from my dissertation study in one class and integrated across courses through our curriculum. Because we understood that if clinical judgment development was going to be sustainable, then this strategy needed to be something that was integrated across more than just one course.

Hillary Gamblin:

So you saw this critical need to help students with clinical judgment. How did you tackle this? I mean, that’s what? 60% of the people in the poll are saying, “I don’t know where to start.” So what was the plan and what was the end goal?

Christina Phillips:

I’ll start with just a little bit more background to that. We recognized the problem first of all, Laura helped us get there and see some of the big issues. But the research really supports that we had a huge crisis in front of us in pre-licensure nursing. Students ability at graduation to be competent and going into their first nursing practice continues to show that students are lacking in the competency they need, where they need to be in order to practice safely. We recognize that students need a good ability to complete judgements, in that about 50% of the task that nurses do require judgements. So nurses are making judgements all day, every day, which all nursing educators know. And then finally, we also recognize that still a huge amount of patients are dying every year from medical errors and things that could have been prevented. Of course, nurses are that last line of defense in so many cases for preventing patient safety errors. And then finally we thought about the implications of Next Gen, as many of you all are considering. Laura, will you go to the next slide?

Christina Phillips:

So additionally, I’m going to speak for just moment about Laura’s research. She mentioned that she studied clinical judgment for her dissertation, and what she found in that was a couple of really interesting things. So first she found that not only can students learn from … we knew that students could learn by participating in simulation, but she showed that students, by by observing simulation in the classroom, can develop clinical judgment. And in addition to that, it only takes two doses of observation of simulation in the classroom to develop student clinical judgment. So that was a really significant and interesting finding. So that gave us a nice evidence base for deciding to go forward with integrating judgment in the classroom. To that end, knowing that two doses of simulation helped develop clinical judgment in the classroom, we thought, “Hm. If two doses are good, perhaps more doses would be even better.” So we developed a total of five experiences across the first year of the curriculum, with three of those being in the first semester. And the goal was to improve clinical judgment across the student experience.

Christina Phillips:

And then if you’ll go one more forward, Laura. Thank you. And then just a few nuts and bolts. How did we prepare the students for the simulation based experience? First, we introduced the concept of clinical judgment in our Nursing Foundations course. Jessica is going to speak more about that in a moment. And then the actual simulations happened at the midpoint of the semester, so our students just in the past week did their first simulation in the Pathophysiology course. And in that case, it was an infection exemplar, and students had covered infection content in Pathophysiology and Foundations, as well as learning about antibiotics and pharmacology. And then coming up in November, 1st of December, we’ll do another simulation in a pharmacology course that will cover content related to cardiovascular systems that has been taught across the three courses.

Hillary Gamblin:

Fantastic. It’s always helpful to share examples and demonstrate how these concepts and models and strategies work. Can you share with us what an application of this would look like?

Jessica Gay:

Sure. So I can start this since I’m the one that starts it with our students. So we’ll kind of show you here chronologically how it goes. So in week one, I have these students in the Fundamentals course, or your Foundations course. So we’re a concept based curriculum so we start by just introducing the concept. It’s the first week, these are brand new students, they’re really laypeople, it’s only our second class. So this is our basic sort of objectives for that lesson. We define clinical judgment, we talk about why it’s important to nursing practice with a lot of the information we shared in our background slide, and then we describe each step in Tanner’s Model. And then we use the nursing process and Tanner’s steps with the students and take them through them to help formulate a plan of care. Will you advance that for me please?

Jessica Gay:

So these are just kind of our general lesson objectives that we use. So we use a total of two class periods, so that’s four classroom hours. They have a reading assignment and a quiz that they complete before they come to class. When we get to class, we introduce a concept using a standardized format for concept introduction, and then we spend a lot of time doing in class application of Tanner’s steps. And then after class, they have a homework, a synthesis activity.

Jessica Gay:

There we go. So this is … if you’re not real familiar with it, this is Tanner’s Model of Clinical Judgment. So we spend a lot of time specifically teaching the students the steps and sort of stop and practice each one as we go. So if you look at this graphic, we begin with the ethical perspective and sort of the expectation that the nurse has walking in the room, and then we go through each of the four steps. So when we talk about noticing with the students, we ask them, “What did you notice about this patient?” We’re trying to get them to recognize those cues. Right? So, “What are you getting from your assessment? What are the signs and symptoms? What about the history in the EHR? Are you validating your data? Which data is significant and which is not significant?

Jessica Gay:

And then we move on to interpreting, which is sort of asking, “Well, what does all that mean?” So we’re having them analyze the cues that they noticed. So clustering together relevant data and irrelevant data. “What additional data do I need to collect? What’s the comparison of what I’ve discovered to maybe the trend of this patient before or a standard of what’s normal?” Then we talk about generating a hypothesis or kind of generating a problem list and sort of goals and outcomes for that patient, and then we prioritize it.

Jessica Gay:

And then we move on to the third step, which is responding, which is, “What am I go going to do about it?” Right? So we talk to the students about taking an action. They need to choose their interventions. They need to decide according to their priorities which interventions are needed immediately? Which ones can I delegate? What communication do I need to have with other members of the interprofessional team to get this done? And then the fourth step, of course, is reflecting. So, “Did it work? What was the effect of what I did? Did the patient meet the outcomes that I had set? Do I need to change my plan? Do I need to change my thinking? Do I need more data? What other things do I need to continue to monitor for the safety of this patient?”

Jessica Gay:

Thanks. So I love this graphic because if you’re like me, you may have been trained using nursing process or ADPIE. That’s what I was trained in, and so I love this because it integrates ADPIE here with Tanner’s Clinical Judgment Model that we use. And then it also has there in the middle, the Clinical Judgment Measurement Model on which the Next Generation NCLEX is being designed. So it’s a nice way to see how those pieces fit together.

Jessica Gay:

So this is just an example of a case study that we use when we’re practicing going through the steps in class. Your nurse educators, you write little cases like this all the time. We gave this patient some pretty standard problems. Right? With mobility and a wound and pain and some other things. So it’s just a way for us to have a reason, a patient to go through each of the four steps with the students.

Jessica Gay:

So because we are a concept-based curriculum, when we get through a concept introduction, we always choose an exemplar to sort of practice and apply. So you could choose any clinical decision. In this case, we choose to have the students choose which blood pressure cuff they’re going to use. Because it’s the first week, that’s about all they’ve gotten so far in the skills lab. So we go through it in the same method as we did when we were practicing. So we talk about the first step of noticing, that includes your physical assessment. “How big is this patient’s arm? What size cups do I have available? Are there cultural or environmental concerns?” And then we move on to interpreting. So, “Based on your experience in how to make a choice, why do we need to take this blood pressure in the first place? What size cuff is going to give me an accurate reading for this specific patient based on what I know about blood pressure cuffs?”

Jessica Gay:

So then the next step is responding, so carrying out the action. You’re going to have them tell you, “Okay. We’re going to choose a cuff for this patient. We’re going to take the blood pressure because you know that skill, and then you’re going to reflect on what you found out.” So is your value accurate? Do we need to change the cuffs or the site? Did we make the right clinical decision or do we need to change something? So, “Based on what we’ve learned, what will we do for the next patient? Are we going to choose our cuff differently?” And then finally we always have students talk about what are you going to teach the patient about this? What does a patient need to understand about how blood pressure cuff size might affect the value that is received when you get a blood pressure reading? So you can see how we introduce and work with clinical judgment as a concept in that very first week of this semester. So I’m going to hand it over to Laura to tell you what happens a few weeks later in week eight.

Laura Klenke-Borgmann:

Alright. Thanks. So after they get that really solid introduction to the concept of clinical judgment, in week eight we really try to contextualize that for them and really apply it. So in week eight, the concept of infection is taught in the Fundamentals course and in Pathophysiology and actually in Pharmacology. They learn antibiotics right around that time as well. And so it’s later in this week eight that we actually do our first of our in-class simulation-based experiences.

Laura Klenke-Borgmann:

And so I’m going to explain a little bit about how this works. So a few days before the simulation was to be observed in the classroom, it was pre-recorded. And since it was very early in the semester and the students hadn’t even been to clinical yet, we decided that we, as the faculty, would be the nurses in this first scenario that they observed. And so we cared for a simulated patient that was a 70 year old female with a urinary tract infection coming to the hospital from a rehab facility. And the entire scenario in whole was approximately 20 minutes.

Laura Klenke-Borgmann:

And so then the next day in the regularly scheduled Pathophysiology class time, the recording was shown to the entire class. And you can kind of see how this works here. The students, they’re sitting in the class at their sort of six person round tables, watching the case unfold on these large monitors all around the room. The students were also given a worksheet to promote engaged observation as they watched the case. And again, the questions on the observer worksheet were based on those four phases or aspects of clinical judgment that Jessica went over. And so we conducted the experience in kind of this stop, start, stop, start nature with each section of the worksheet, and here it is for you just to kind of get an idea what that looks like, with each section of that observer worksheet guiding the student’s observation as the case unfolded.

Laura Klenke-Borgmann:

And so what we thought might be fun here to do next today, it might be valuable to kind of show you how we do this. And so for the next part, we kind of want you to kind of put yourself in the shoes of the students. And so what we’re going to do is we’re actually going to watch the first part of this scenario. And as you watch we certainly want you, just as we ask the students to do, to pay particular attention to this first question on the observer worksheet. So as you watch, did the team perform a focused observation, recognize deviations from expected patterns, and seek more information? And so we’ll watch a clip of this video, and then immediately following what we would do is we would have the students kind of self debrief in their small groups at their individual tables for about five minutes or so and then we’d come back together as a large group together and debrief as a large class.

Laura Klenke-Borgmann:

So what we’re going to do is we’re going to sort of give you an example of what this scenario looked like. So I’ll meet you on the other side.

Speaker 5:

Hi guys.

Jessica:

Hello.

Speaker 5:

Are you guys the two nurses taking over for Ms. Johnson?

Jessica:

Yeah.

Speaker 5:

Okay, I’m Laura. I was the nurse taking care of her before. I’ll give you guys a brief update on what I know so far.

Speaker 5:

She just recently got here from an ambulance. So this is Ms. Ingrid Johnson. She’s an 81 year old female with a past medical history of diabetes mellitus Type 2 and hyperlipidemia, and she has a surgical history of a total left hip replacement, actually just five days ago. She presented to the ED today from an inpatient rehab facility with painful urination and some mild confusion, which is new for her. She’s usually completely [inaudible 00:21:19]. She stated that she has been experiencing some burning and difficulty with urination for the last two days. And this morning when she woke up, she had a fever of 39 degrees Celsius, which is a 102.2 Fahrenheit, and was flushed and confused. So her nurse at the facility is the one who actually called the ambulance to have her come to the ED. Her daughter was also here when she first got triaged and told the nurse that the patient is five days post-op from hip placement. I think I might have told you that already, but she did have a catheter placed during that hospitalization.

Speaker 5:

So I got her back here into the room from triage about 10 minutes ago. She’s just been A&O x1 for me. She knows her name and that’s about it. She thinks she’s at her sister’s house and she thinks it’s 1975. I got her into a hospital gown and her heart rate from ambulance was 123, her blood pressure was 94-70, her respiratory rate was 20, and her pulse ox is 96% on room air. And I was able to go ahead and get a 20 gauge IV placed in her left forearm and sent off some labs. I sent off a CBC with differential, basic metabolic panel, C-reactive protein, and an erythrocyte sedimentation rate. And I was actually also able to get a urine sample from her, and I sent that off for a urinalysis. But there really have been no other orders placed yet for her. So besides that, I haven’t done much for her yet. Is there anything else I can answer for you or do for you before I take off?

Jessica:

I don’t think so.

Speaker 5:

You guys okay?

Jessica:

That pretty much covers it.

Speaker 5:

Alright. Well you guys have a good day. And Ms. Johnson, these nurses are going to take over for you. You’re in good hands. Okay? You take care. I hope you get feeling better.

Sarah:

Hi Ms. Johnson. This is Jessica and I’m Sarah, and we’ll be the team taking care of you today. Could you tell me your first and last name and date of birth please?

Ingrid Johnson:

Ingrid Johnson, and my birthday is in may.

Sarah:

In May. Which day?

Ingrid Johnson:

I don’t know. Is it on my band?

Sarah:

Is it May 27?

Ingrid Johnson:

Yes.

Sarah:

Okay.

Ingrid Johnson:

That sounds right.

Sarah:

Alright. I will listen to you, get some vital signs while Jessica asks you a few questions. Okay?

Ingrid Johnson:

Okay.

Jessica:

Hi Ms. Johnson. I’m going to look a little bit at your lab reports that just came back, but I’d like to ask you a few things too. Can you tell me how you’re feeling right now?

Ingrid Johnson:

I feel kind of warm and my lower back hurts.

Jessica:

Right back here?

Ingrid Johnson:

Yeah.

Jessica:

Okay.

Ingrid Johnson:

And it hurts when I pee.

Jessica:

Oh, I understand. Okay. Okay. So you’re hurting in your back and it hurts when you pee. How long has that been going on?

Ingrid Johnson:

A few days.

Jessica:

Okay. Every single time that you go pee?

Ingrid Johnson:

Yeah, it hasn’t gotten better.

Jessica:

Okay. And how long have you felt sort of hot and feverish and stuff?

Ingrid Johnson:

I don’t know. I haven’t felt good this morning so.

Jessica:

Okay. Okay. Well, that makes sense. So let’s see. Can you tell me, are you allergic to any medicines that you know of?

Ingrid Johnson:

I don’t think so.

Jessica:

Okay. And I understand that you had a hip surgery a few days ago. Is that right?

Ingrid Johnson:

Oh yeah. Yeah. I think that’s what’s on my other side. Yeah.

Jessica:

Okay. So Sarah is going to have a look at that whenever she’s done checking your pulses and things. So that’s good. So any other kind of surgeries or being in the hospital lately, other than just your hip?

Ingrid Johnson:

No, I don’t think so.

Jessica:

Okay.

Ingrid Johnson:

I know I take medicine though for things.

Jessica:

Okay. Do you remember what for?

Ingrid Johnson:

So I have diabetes so I take something for that, but I wish I knew what it was called. And I know I take something for my cholesterol because I’m always getting in trouble for eating something I shouldn’t.

Jessica:

Oh yeah, it’s right here. So on your medication list, I see you’re taking Metformin for your diabetes. Does that sound familiar?

Ingrid Johnson:

That sounds right.

Jessica:

Yep. And Atorvastatin for your cholesterol.

Ingrid Johnson:

Oh, okay.

Jessica:

Yep. Okay. So that pretty much covers your medicines and everything. So can you tell me, why did they bring you here from the rehab facility this morning?

Ingrid Johnson:

There was a lady who called. I don’t know exactly why she did that, but I’m hoping it’s because I don’t feel good.

Jessica:

Well, I’m sure that she was worried about you. So we’re going to look at some things and see if we can figure out how to make you feel better.

Ingrid Johnson:

That would be great.

Jessica:

Sarah, what did you find out?

Sarah:

So she is breathing 20 times a minute, which is a little bit on the fast side. Your blood pressure is a little low, it’s 97-70. Your heart rate is high, you’re tachycardic is what we call it, 123. And you do have a fever of 39 degree Celsius, which is 102.2 Fahrenheit. You’re also kind of, we say, diuretic, like a little wet on your skin. She is breathing well, airway is clear. She’s tachycardic. Now Ms. Johnson, there is just one question that we ask every patient.

Laura Klenke-Borgmann:

Okay. So you kind of get an idea for what that first first clip of the scenario looked like. And so then after that clip would finish, like I said, we’d have the students kind of self debrief that first question on the observer worksheet together amongst themselves, and then we talk as a group. So, “What did you guys notice? What did the team do? How did they perform an assessment? What information did they gather?” And then after we kind of debriefed on that for a while we say, “Okay. Now what do you think should happen next? What should the nurses do? What should be their interpretation and their plan?” And then we’d hit play again and start the next section so that the students could watch the case unfold and continue. So you kind of get a taste for what that experience feels like. And then we would proceed to continue to watch the case unfold as we work our way through that observer worksheet. So you kind of get a taste for that.

Laura Klenke-Borgmann:

Then fast forward in the semester to week 16, we do another in-class sim. This time coronary artery disease had recently been covered in the Pharmacology course and in Patho. So anti-hypertensives and anti-arrhythmics in Pharmacology, and Coronary Artery Disease and Angina in Patho. And so again, later in that week to sort of really show the students how these courses absolutely build and integrate with each other, we showed an in-class simulation in the Pharm to sort of show that Patho and Pharm integration. So same thing, same setup. Stop, start nature guided by that observer worksheet for the students.

Laura Klenke-Borgmann:

And this time for the presentation purposes to kind of give you a different example, we’re going to kind of fast forward in the clip and show you a part of the recording that’s pertinent to this second question that we would have the students focus on. So this time on the interpreting. So, “Did the team prioritize data appropriately and make sense of the data?” And so you’ll see now we’re going to watch a short clip, shorter even than the one before. This time you’ll see, in this Coronary Artery Disease case, that we actually had two students from the class volunteer out of the goodness of their hearts to participate as the nurses in this case. And so now we’re going to pick up with them sort of mid-care and really focus on that interpreting part.

Speaker 10:

Take a minute here Mr. Matthews and kind of discuss what we need to do next. Okay?

Speaker 11:

Oh, okay. Alright. Do you have that oxygen going because it feels like it-?

Laura Klenke-Borgmann:

Forgot to mention. This is a 68 year old male presenting to the emergency department with unstable Angina that our two nurses are caring for.

Speaker 10:

Yes.

Laura Klenke-Borgmann:

Okay. I feel like it is helping a little bit.

Speaker 10:

So I looked, he did get the troponin back. It’s showing that it’s not elevated so.

Speaker 12:

There’s nothing.

Speaker 10:

It’s less than 0.04 so I don’t think that’s something to be concerned about right now. But his EKG did show a depressed, or I think it’s a depressed T-wave. So there is probably some-

Speaker 11:

What’s that mean? Depressed T-wave, what the heck is that?

Speaker 10:

So when they did the little EKG with the monitors on your chest, it was just showing some electrical activity of your heart. And so it was showing that because of this lack of oxygen, that your heart was struggling a little bit to work here. So hopefully with oxygen and then some medications that we’re going to give you, it’s going to help regulate that a little better. Okay?

Speaker 11:

So you don’t think I’m getting enough oxygen to my heart.

Speaker 10:

That’s what it looks like. That’s what-

Speaker 11:

Oh my gosh.

Speaker 10:

-Angina and chest pain can be sometimes.

Speaker 11:

So that’s what’s going on whenever I have the chest pain when I’m walking?

Speaker 10:

Yeah, yeah.

Speaker 11:

Oh my gosh. Okay.

Speaker 10:

It’s called Angina.

Speaker 11:

Okay.

Speaker 10:

And so probably from here on out … I mean, you’ll be able to talk to your doctor and he can give you some medication so that the nitro that you can use when this happens, so hopefully you won’t have to keep coming back in here. And so we’re going to go ahead and give you some of that-

Speaker 11:

Okay.

Speaker 10:

-right now. And then probably some other meds too to help just open up those blood vessels to your heart and get that oxygen going.

Speaker 12:

And it looks like your oxygen level is gone up now.

Speaker 10:

Yeah, you’re at 92 already.

Speaker 12:

92 now.

Speaker 11:

Thank you. Thanks guys. I appreciate that. Noone has ever explained it to me like that before. I appreciate that.

Speaker 10:

Right. Yeah. And your color is looking great. So alright.

Speaker 12:

Temperature?

Speaker 11:

Temperature is 37 degrees Celsius, and his skin feels warm.

Speaker 12:

Okay.

Speaker 10:

Alright. So I’m going to go ahead and follow this chest pain-

Laura Klenke-Borgmann:

Alright. So again, you can really see how the nurses were asked to interpret what they found from their assessment, and the students observing were able to do the same and really be able to think about how did the nurses make sense of it, what did that look like, and really contextualize their learning. And so again, we would go through the entire scenario in that stop, start nature with the observer worksheet. So that kind of, Hillary, wraps up kind of our explanation of what this kind of strategy looked like spread across the semester.

Hillary Gamblin:

I’m muted. I’ve never done that before. Thank you for sharing that. That’s really an honor. After completing this new approach with preparing your nursing students, what lessons did you learn? What would you keep doing the same? Is there anything that you would change? Yeah. What were the takeaways for you as you did this with your students?

Laura Klenke-Borgmann:

Yeah, absolutely. One of the things that really stood out to us in terms of student feedback and student responses is, in one of those debrief sessions in the classroom after the in-class sim experience, we had a student as part of the feedback and the debriefing experience say something along the lines of, “Oh my gosh. Oh my gosh. I feel like everything that I just learned in the last eight weeks of nursing school and all of my different courses just all came together in the past 20 minutes of watching this recording and putting the pieces together.” So that was pretty darn exciting. We were high fiving each other in our minds in the room because that’s exactly what we wanted. We want the students to be able to contextualize their learning and make sense of what they’re seeing in the classroom and be able to pivot and actually apply it to the real world, that Pharm and Patho and Fundamentals and all the other courses that they’re getting really does matter and this is why. And so that was pretty cool.

Laura Klenke-Borgmann:

In terms of our own learning and our responses, we have really seen that it encourages students to critically think beyond just the confines of classroom memorization and really contextualizes their learning for them. And so we’re certainly interested in evaluating expanding the strategy across the curriculum into subsequent semesters of the program and not just in this one semester or in these three courses, so to speak.

Hillary Gamblin:

Well I think you’ve answered all of my questions, and I asked a lot so thank you for doing that. I’m sure these resources and ideas has sparked ideas and questions among those participating in today’s workshop. So we’re going to take the next 10 or 15 minutes to do a live Q and A. Again, if you’d like to submit a question for the Q and A, there is a tab just below the video feed. My colleagues have been monitoring your questions and selected a few that we can ask this trio. So we’ll wait for you to guys to enter some questions.

Hillary Gamblin:

Maybe I’ll go ahead and ask another question since I’ve actually thought of something.

Laura Klenke-Borgmann:

Sure.

Hillary Gamblin:

So you said you’re going to try doing this again in another semester, have you convinced other faculty to do this with you? So it’s not just you three, but maybe six or nine other people that are trying this and see what results you get?

Laura Klenke-Borgmann:

Sure. I mean, that’s kind of how it all started. That’s kind of the origin story in the first place. Right? Was me having this idea and then sharing it with Chris and Jessica, who were interested and excited to try it as well. But yeah, absolutely. We’d love to encourage other faculty members to participate in this type of strategy. And I think it would be really cool to do it in not just courses like Pharm and Patho, but also other courses that may not seem as obvious that would also be super powerful and really valuable to do kind of these learning vicariously through observing these real world cases. So absolutely.

Hillary Gamblin:

Okay. We have a first question from our participants. It says, “How do you see the strategy being implemented in non-clinical Patho courses? EBP, QI, Leadership, et cetera.

Laura Klenke-Borgmann:

Yeah, great question. That’s kind of exactly what I was kind of alluding to when I said not just your kind of more clinical based courses. And I think that’s exactly right. I mean I think any situation in which you see students in any of those courses, be it EBP, be it Population Health, be it Professionalism courses. I think any gap or any problem that you see students having could absolutely be filled with some type of scenario in which they watch and they can debrief. So I absolutely think it doesn’t have to be just the clinical based courses. So any gap or problem, I think, can be filled with some of this observing and learning through bringing those situations into the classroom. That’s a great question.

Hillary Gamblin:

We have another question. How will you level it up for the second year?

Laura Klenke-Borgmann:

Oh, that’s an excellent question. That is a great question.

Jessica Gay:

Well, we’ve only chosen the first semester. I wonder if you should talk about the second semester.

Laura Klenke-Borgmann:

Yeah, that’s true. We have continued. Now what we shared with you today was sort of the pilot of what we did in terms of showing how we integrated these in-class sims across several courses. And it, for sure, occurs in the fall semester for our junior level students. We have now added doing these types of in-class simulations in the spring semester as well. In that, again, trying to integrate if we’re talking about it in Pathophysiology and it’s being talked about in Fundamentals to do more of these in-class sims. And we did do that in terms of leveling up, we did add them now to the spring semester as well. What we described today is sort of our pilot in the fall. But yes, we have added them the year, not just the one semester.

Jessica Gay:

To answer your question kind of for the second year, we haven’t started that yet. But I think part of the way we will level it up, so to speak, will probably be to increase the complexity of the patient scenarios. The same way that we do in courses in general, it gets more difficult. The patients have more comorbidities, those kinds of things. So I think that’s probably the way we’re going to go.

Hillary Gamblin:

Do you provide your students with a scenario and patient chart ahead of time or provide them with a focus readings for preparation? Anything like that?

Laura Klenke-Borgmann:

Yeah, good question. So the preparation ahead of time is truly the didactic coursework that they’ve done up until this point. So any of the reading or the notes or the slides or anything that we have done up until this point has been sort of their prep and their preview for this experience. Because we truly are not introducing anything new in these cases, it truly is just contextualizing and showing them, “Okay. We talked about Coronary Artery Disease in the classroom. Now look guys, this is what it looks like. This is what the patient complains of. This is what the nurses have to think about and these are the questions they have to answer.” So no new content is brought up in these cases, it truly is just building on what they learned that week in the didactic portion of the class.

Laura Klenke-Borgmann:

But yeah, great question about providing them patient chart. Yes. In our learning management system, we use Blackboard, we have the patient’s chart uploaded for them so that they can see all of the patient’s information, history, labs, vital signs, all of that. We have that available to them in our learning management system so they can be referring to that as they’re watching the video. Yeah, great question.

Hillary Gamblin:

Our next question says, “As department chairperson, I need to assist faculty to integrate these strategies. Any information on stimulating their creativity in these draining times in healthcare?”

Laura Klenke-Borgmann:

Oh right. That is a great question. I think, and Chris and Jessica definitely jump in here, the one thing that I would say is that I think one of the things about this type of strategy is that it can be pretty low resource. It’s not like … we just filmed on an iPad. We used the resources that we had here in our school to make these brief videos and we’re able to just show them in the classroom. So to me I feel like it’s kind of an evidence based strategy, but also kind of low resource that can be easily done. And these cases are just … I mean I wrote these two cases particularly that we showed, based on INACSL standards if people are familiar with that, but from our own clinical experience. So just drawing from our experience kind of made these come alive and didn’t feel too onerous necessarily to get this done in the classroom. I don’t know if Chris and Jessica have anything to add about that.

Jessica Gay:

Yeah, I agree. I mean, the thing is your faculty are tired. Right? They’re worn out and they’re tired of coming up with new, exciting ways to do things in light of the pandemic. So the beauty of this strategy is you don’t have to reinvent the wheel. You can use a case study that they’re probably already using in class to teach whatever your content is and just apply the clinical judgment model when they practice. Just act it out, film it. You don’t have to have a bunch of equipment, you don’t necessarily have to have a bunch of tremendous financial resources. And because the students have to then go through the steps of filling out that observer worksheet, they’re doing the judgment steps and your faculty don’t have to come up with something brand new.

Hillary Gamblin:

Which is refreshing because I feel like sometimes in nursing when you think you have to come up with something new, it’s either a lot of money or a lot of time. Right?

Laura Klenke-Borgmann:

That’s right. That’s definitely right. And that’s certainly not the case for this strategy. It can be done. Like I said, it was pretty low resource, yet high impact, evidence-based strategy to do.

Hillary Gamblin:

Okay. We have one more question. If you have any more questions, please submit them. I think we have enough time to do one or two more if you want. The question is, “Do you anticipate in later courses to have two patient situations, like two ER admissions, and who to see first and why?

Laura Klenke-Borgmann:

Oh, I would love that. I would love to be able to. Again, kind of in that leveling up conversation we had a few minutes ago, I would love to be able to add some complexity about prioritization and delegation, adding that. And I think that is absolutely something that could be done, again, as you do level up, as you move through the curriculum. And now we’re looking at seniors in their fall and especially spring semester, I think that type of scenario would be awesome.

Laura Klenke-Borgmann:

The other thing I will sort of add to that that has crossed my mind that is sort of like, “Hmm. This might be fun.” Is if possible to kind of do it live almost and then have the observers kind of … instead of the way we did it was like, “What do you think they should do next? Well, let’s hit play and see what they did.” Right? Instead of doing it that way, to truly have the observers kind of guide them in what should be done next. Sort of like a choose your own adventure kind of scenario. I think that would also really level up the experience and do more in terms of prioritization and delegation and thinking on your toes. So there’s a lot of really fun, creative ways you could take this for sure.

Hillary Gamblin:

Fantastic. Okay. Oh, we have one more. We have someone asking if you can provide a copy of the worksheet that you give them.

Laura Klenke-Borgmann:

Sure. Yeah, absolutely. I don’t know how I go about that Hillary, but I’m more than happy to share. Yeah.

Hillary Gamblin:

Share it with me and then we actually share an email after this with a link to the recording, all the slides, and so we can add that, just slip that in so you guys have everything that we’ve talked about and everything that’s been used today so.

Laura Klenke-Borgmann:

Okay.

Hillary Gamblin:

We can for sure do that. Okay. I think we were able to answer everybody’s question, which is fantastic. We appreciate everyone taking the time that submitted one. Your questions are what make these workshops invaluable resources that happen in real time. So before we end, I like to ask our guests to share three takeaways. So if you could give our audience three takeaways when it comes to integrating clinical judgment across pre-licensure programs, what would it be?

Jessica Gay:

Yeah. So I can do that. So the takeaways about these SBEs, the Classroom-Based Simulation Experiences, is we know that they develop clinical judgment in our pre-licensure nursing students. And if you’re like us, if you’ve been a nurse educator for any amount of time, you’re fighting the memorization battle. Right? And these kind of strategies will really encourage your learners to think about a situation and problem solve their way through, not just memorize what are the next steps. And again, as we already talked about, they are a low resource strategy. It’s evidence based. You don’t have to come up with a whole lot of new things. You don’t necessarily need a high fidelity mannequin with a lab behind you to execute it so.

Hillary Gamblin:

Those are a great wrap up. Thank you so much. Thank you to all three of you for sharing your expertise with us today. You did this workshop voluntarily. We appreciate you taking your personal time to be with us. As a thank you to those who’ve joined us live to show our appreciation, we’ve randomly selected a participant joining us live to win a pair of AirPod Pros, which is like my favorite piece of technology. So you are about to be very, very happy. Catherine Conrad at University of Oklahoma, so we will be sure to reach out to you and figure out a way to get you those AirPod Pros. We do a drawing with our participants for every workshop for every month. So if you didn’t win this time, come back next time.

Hillary Gamblin:

As I said before, we know that this workshop will be particularly valuable to everybody that signed up so we are sending that email again just to remind you with a link of the recording from today, the slide deck, and that worksheet that they promised. So watch for that in your inbox. But that’s it for today. Thank you to our participants. Thank you to those working behind the scenes that make this possible. And of course, thank you to our guests, Laura, Jessica, and Christina. We will see you next time.

Jessica Gay:

Thank you.