1. Toto, Diane L. MSN, RN

Article Content

One important role of nurse educators is to help students learn to use clinical judgment to make sound nursing decisions. Clinical judgment is the ability to take action (or not) based on the analysis of empirical information related to a specific situation.1 These skills, which impact a nurse's ability to provide safe care, develop through education and experience.2 Faculty understand that nursing students lack experience in clinical judgment when it comes to interpreting the needs of the patient.3 Many times, this is due to the inability of students to recognize subtle changes in the patient as the patient's health status worsens. Students lack experience in making connections between signs and symptoms and the patient's acuity level. Many students fail to notice when a patient is deteriorating; noticing is a critical prerequisite for nursing action.4


Levels of Sickness Teaching Strategy

It is important that newly licensed nurses be prepared to manage clinical deterioration events to achieve optimum patient outcomes.5 The Levels of Sickness Teaching Strategy helps students recognize clinical deterioration in a timely manner by understanding the meaning of a wide range of signs and symptoms. This teaching strategy, referred to as the Sick tool, can be used in the classroom, simulation, and clinical settings. The Sick tool is a broad paradigm through which nursing students are encouraged to recognize patient deterioration across a wide range of conditions and illnesses.


The Sick tool is based on David Ausubel's Meaningful Learning Theory. The tool is linear in nature progressing from simple to complex, links previous knowledge to new knowledge, has a logical meaningfulness (substantive and relatable) to the subject matter, and is student centered. The graphic design incorporates Ausubel's6 use of an advanced organizer, primarily that of a comparative organizer. A comparative organizer is used to integrate and progressively differentiate new details about a subject matter. Comparative organizers bring into the working memory of the learner what may not have been initially recognized as relevant.


The Sick tool should be completed at the end of a learning encounter and address one specific illness at a time. This activity is teacher-led at the beginning of the semester, student-led by midsemester with facilitation by the instructor, and completely student-driven by the end of the semester.


The Sick tool is divided into three acuity levels. Based on the specific illness being discussed, students should identify each of these levels: the signs and symptoms patients would exhibit when starting to get sick, when getting sicker, and, finally, at their sickest (see Figure, Supplemental Digital Content 1, The lesson objective for students is to differentiate signs and symptoms of a deteriorating health status related to a single illness into acuity levels. It is important to select teaching strategies that support the objectives and engage students in higher-level thinking than what is possible with lecture.7


Students were asked to do a Sick tool learning activity at the end of a class on gestational diabetes. Students were instructed to differentiate the levels of acuity that a patient with gestational diabetes exhibits as the disease progressively worsens. For example, in the first section, labeled "sick," students listed symptoms such as tiredness, lack of energy, and possible yeast and urinary tract infections. In the second section, entitled "sicker," they recorded signs and symptoms such as pronounced fatigue, polyphagia, polydipsia, increased urinary output, high Accu-Check readings, dry mucus membranes, and headache. In the third section, labeled "sickest," students listed fruity odor to breath, prolonged decreased fetal movement, stillborn, severe dehydration, critically high blood sugar, ketones in urine, coma, and death. To use clinical judgment effectively, students need help understanding the practical manifestations of textbook signs and symptoms, noticing significant changes in the patient's condition, and learning distinctions among a wide range of possible manifestations.8 The Sick tool is effective for this learning.


Evaluation of Learning Outcomes

To evaluate whether the Sick tool improved the student's ability to notice clinical deterioration in the patient's condition, several questions were presented on an examination. The test questions addressed a single disease entity and a level of sickness in the patient that required students to recognize the significance of signs and symptoms and choose the correct nursing intervention. For example, with a multiple-choice question about a patient at 34 weeks of gestation in ketoacidosis, the students needed to recognize that the patient was at her sickest level and required an immediate nursing action. In another question in which a patient with gestational diabetes called the nurse at the clinic to report a change in her symptoms, the students needed to identify this as a deterioration with the patient moving from sick to sicker. On assessment, 70% of the students recognized the need for immediate nursing action, and 86% recognized patient deterioration. These results have been consistent for several semesters.


In the simulation laboratory, a scenario was implemented of a pregnant patient with severe preeclampsia on magnesium sulfate. During the debriefing phase, students recorded the patient's acuity level on an index card with a rationale (sick, sicker, or sickest). Ninety percent identified the correct level (sicker) and supported their answers. By asking students for the rationale underlying their thinking, the "why" becomes integral and is seen as part of a process that now has meaning.9



Nursing faculty can use the Sick tool as a simple teaching and learning strategy to help students recognize clinical deterioration. The tool can be used in the classroom and simulation laboratory but has the greatest impact in clinical practice. Using the Sick tool in postconference encourages students to evaluate their use of clinical judgment when reflecting on patient care. Applying the Sick tool at the bedside allows students to use clinical judgment while observing signs and symptoms in the context of a real-life patient situation. The Sick tool can be adapted to other experiences nursing students encounter in the clinical setting such as preparing patients for discharge. Students can use the tool to alert patients and families about complications and symptoms that require a call to the physician (sick) or a visit to the emergency room (sickest). Promoting students' clinical judgment has the potential to improve patient outcomes as the novice nurse enters into practice.




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