1. Pence, Patricia EdD, MSN, RN

Article Content

Recently, the National Council of State Boards of Nursing (NCSBN) designed the National Clinical Judgment Measurement Model (NCJMM) as an integrative framework to measure clinical decision-making skills and competencies of entry-level nurses.1,2 The NCJMM will be used to develop future test items on the NCLEX. The NCSBN and nursing education experts recommend that educators begin teaching clinical judgment in prelicensure nursing education so nurse graduates are better prepared for the Next Generation test items, which will include case studies with 6 prototype test items.1,2 This article describes how the author combined the think-aloud (TA) approach with Next Generation case studies as a teaching strategy to model clinical judgment in a prelicensure BSN first-semester nursing course.


TA Approach

TA has been an innovative teaching strategy used by educators to build clinical reasoning skills among students in medical training and nursing education.1,3,4 Previous literature noted the benefits of TA to develop nursing students' thought processes while performing a physical assessment.4 This strategy also applies when educators verbalize and explain their thinking used to identify and organize relevant information and describe the steps used to make decisions that solve a clinical problem. Thus, when educators use TA, it provides students an opportunity to learn how an expert clinician might think in relation to caring for clients.3


Next Generation Case Studies and TA

After attending a virtual conference sponsored by the NCSBN, the author began writing case studies using the Next Generation prototype item format. The case studies were used as a teaching strategy in a pathophysiology pharmacotherapeutics nursing course. TA was an additional method used to build clinical judgment skills in 2 case studies on clients with dyslipidemia and hypertension. A comprehensive explanation of the case studies using TA was recorded. Several examples describing how an expert nurse might think were as follows: "Here I would be concerned about... because..."; "We are always watching for that particular adverse effect...." Pausing throughout the recording provided time for students to read, process the information heard, and respond independently to the case study items before the explanation. Each recording of approximately 25 minutes was posted online in the nursing course.


The enhanced hot spot/highlighting, matrix/grid multiple response, and drop-down cloze items were 3 Next Generation prototype items written in the recorded case studies.2 Several open-ended response items were also included. The Next Generation case studies were shown as a Word document on the computer screen during the recording. Each case study began with learning objectives and a brief scenario, followed by a simulated client medical record with a tab section for the nurses' notes, vital signs, and history. TA and the highlighting feature of Word were used to identify and click on relevant information in the signs and symptoms of diseases, vital signs, and history. The case unfolded over time with new information that required further teaching and monitoring by the nurse, such as an update on the client's condition or additional medications.


Several matrix/grid multiple response items required sorting and organizing of information provided in a table. For example, each row in a table required one response to indicate which teaching statement made by the nurse applied to the medications. TA allowed students to hear how an expert nurse might clinically reason through the medication information to determine the correct response. A sample item for the case study on hypertension included 3 anti-hypertensive medications as shown in Table 1.

Table 1 - Click to enlarge in new windowTable 1. Case Study on Hypertension

Another matrix/grid item in the dyslipidemia case study asked whether the client's statement indicated teaching by the nurse was effective or ineffective. For this item, TA gave an opportunity to explain how a nurse would correctly assess a client's understanding of new medication information. An "X" typed in the appropriate area in each row indicated the correct response. This is illustrated in Table 2. This case unfolded with an update on the client's condition and included an open-ended response item. TA facilitated an explanation on how to clinically think through new assessment information and decide on potential nursing actions during a follow-up visit with the client in a medical clinic (Table 2).

Table 2 - Click to enlarge in new windowTable 2. Case Study on Dyslipidemia

A sample drop-down cloze item ending the hypertension case study required filling in the blanks from a list of choices. TA allowed students to hear how an expert nurse would correctly evaluate outcomes and determine nursing measures to achieve the expected outcomes: "The expected outcome for this client would be to _________and _________. To achieve optimal outcomes the nurse should________, and _________." Responses were selected from a table listing 7 possible choices that included 2 distractors.



This article describes how Next Generation case studies and TA can be used as teaching strategies to build nursing students' clinical judgment skills. The author modeled expert thinking of a nurse using TA in recorded educator-developed Next Generation case studies.




1. Hensel D, Billings DM. Strategies to teach the National Council of State Boards of Nursing Clinical Judgment Model. Nurse Educ. 2020;45(3):128-132. doi:10.1097/NNE.0000000000000773 [Context Link]


2. Ignatavicius DD. Preparing for the new nursing licensure exam: the Next-Generation NCLEX. Nursing. 2021;51(5):35-41. doi:10.1097/01.NURSE.0000743100.95536.9b [Context Link]


3. Pinnock R, Young L, Spence F, Henning M, Hazell W. Can think aloud be used to teach and assess clinical reasoning in graduate medical education? J Grad Med Educ. 2015;334-337. doi:[Context Link]


4. Verkuyl M, Hughes M, Fyfe MC. Using think aloud in health assessment: a mixed-methods study. J Nurs Educ. 2018;57(11):684-686. doi:10.3928/01484834-20181022-10 [Context Link]