Types of Clinical Scenarios

The clinical scenario may be developed around actual or hypothetical patients. Depending on how the scenario is written, this method is
effective for (1) applying concepts and theories to clinical practice, (2) learning how to analyze a clinical situation, (3) identifying problems
and solutions, (4) comparing alternate decisions possible and developing decision making ability, and (5) considering multiple perspectives
in a clinical situation. See Table 1 for an application example of each of these types of scenarios.

Table 1: Types of Clinical Scenarios for Critical Thinking

Applying Concepts and Theories to Practice

The nurse visits a patient who was sent home from the hospital two days after the normal delivery of her third child. The baby is jaundiced
and appears dehydrated. When the nurse tells the mother that she is calling the doctor, the mother begins to cry and yells, "I can't handle this
right now."

1. What are possible reasons for the baby's jaundice? Describe the physiology of this occurrence in the newborn.

2. What should the nurse do now? Why?

3. Select one theory that can help explain the mother's reaction. Analyze the mother's response in terms of this theory.

Analyzing a Clinical Situation

Mrs. K is in her 32nd week of pregnancy. Her ankles and hands are swollen, and her blood pressure is 160/90.

1. Discuss the relationship between Mrs. K's swelling of the ankles and hands and her blood pressure.

2. What additional data should be collected at this time? Why is this information important?

Identifying Problems and Solutions

Mr. Z, 26 years old, was admitted with extensive bums on his face and ears. When walking toward the room, you see him crying while
looking in the mirror. When you walk into the room to console him, he stops and says, "I'm fine now."

1. What are two possible responses you could make to Mr. Z? Provide a rationale for each of these.

2. What problems need to be solved in this scenario?

3. What approaches would you plan for Mr. Z's continuing care? Why would these be effective?

Developing Decision Making Skills

You overhear your friend telling a new nurse on the unit not to worry about wearing sterile gloves when changing the patient's dressings
because "he has an infection any way."

1. What are your options?

2. What are the consequences of each of these options?

3. What would you do? Why?

Considering Multiple Perspectives

Ms. P is 18 years old and dying from bone cancer. She has severe pain that is not relieved with medications. She asks you if she can refuse
her next dose of chemotherapy because it is "not working any way. I am only taking the chemotherapy because my mother wants me to."

1. How would you respond to Ms. P? Why is this an appropriate response?

2. What questions would you ask her?

3. What assumptions did you make about Ms. P?

4. What are issues to be resolved in this situation?

5. What are Ms. P's options?

Applying Concepts and Theories to Clinical Practice

Clinical scenarios help students learn how to apply concepts and theories presented in class or through other teaching methods to patient
situations. Students may be asked to identify different problems given the data, identify additional data to be collected, analyze the case using
specific concepts and theories presented in class, give alternate views of the scenario, and decide on approaches to use in the situation. In
responding to these questions, it is important for students to provide a theoretical rationale that supports their answers.

Analyzing a Clinical Situation

Clinical scenarios can also be used to provide experience for students in analyzing data, differentiating relevant from irrelevant data,
determining missing information for problem solving, and identifying additional data needed before any decisions are made. Ulrich and
Glendon (1999) emphasized the importance of students having experience in analyzing complicated and often incomplete data sets to better
prepare them for the realities of clinical practice.

Identifying Problems and Solutions

If the goal is to promote problem solving, the scenario should describe a clinical situation with possible alternate problems given the
information in the case, or the approaches for problem resolution should be unclear. Questions with this type of scenario might ask students
to:

?? Identify all possible problems in the scenario and provide a rationale for each

?? Describe problems that might be possible if more data were available and discuss what additional information they would collect

?? Propose different interventions and approaches to solving the problems, discuss why they would be effective, and describe advantages and
disadvantages of each

?? Decide on the best approaches for solving problems in the scenario and provide a rationale, derived from theory and research, for their
use.

Developing Decision Making Skill

Clinical scenarios also may be used for developing decision making ability. For this purpose, the scenario may present the case up to the
point of a decision, then ask students to critique the situation and decide what to do. Another strategy is to describe the clinical situation and
the decision of the health professional, then have students provide a rationale as to whether this is the best decision for the situation. Because
the focus of these scenarios is decision making, the questions with the case should routinely ask for possible alternative decisions and the
consequences of each, the decision of the student, and why that decision is the best considering the alternatives.

Considering Multiple Perspectives

Few clinical situations are clear cut, and students need to develop the ability to "think beyond" the obvious in the practice setting. Experience
in considering alternate views, comparing different possibilities, and "thinking beyond" the obvious may be provided through clinical
scenarios. For cases of this nature students should be asked to:

?? Raise questions about the case that influence its analysis

?? Describe multiple problems and issues in the case and discuss alternate ways of approaching them

?? Record the assumptions they made when analyzing the case

?? Identify and compare two or more points of view about the case and provide a supporting rationale for each

?? Take a position about an issue in the case and develop a rationale to support it.

Critical Thinking for Interdisciplinary Education

Providing health care for a given population is an interdisciplinary activity. Rarely can one type of health professional meet the needs of
patients along the continuum of care. More interdisciplinary models of care delivery have evolved as a means of providing coordinated and
cost-effective care in different phases of the patient's recovery.

Future health professionals need to learn about the roles and responsibilities of other providers and appreciate the knowledge and skills of
interdisciplinary team members. This learning includes an understanding of the interventions of multiple disciplines and how to coordinate
them to provide the most effective care to patients. This outcome is important so students appreciate the interdisciplinary nature of patient
care rather than viewing care from only their discipline. Yet, few health science students are educated to participate in interdisciplinary care
(Mitchell et al, 2000).
Critical thinking scenarios are one strategy to assist students in health profession programs to better understand the nature of interdisciplinary
care. Scenarios can be designed to examine how different health providers think through patient care situations, weigh options for care, and
make decisions. See Table 2.

Table 2: Example of Scenario for Interdisciplinary Education

Mr. P was involved in an accident at the factory where he worked resulting in a closed head injury, when he arrived at the emergency
department, the admitting nurse recorded in the medical record that the patient was "restless and incoherent." His vital signs were: BP 130/80
HR 92bpm Respirations 20/minute

After admission Mr. P became increasingly incoherent and drowsy. The physician ordered a computed tomography (CT) scan that showed a
left-sided epidural hematoma.

1. Describe the pathophysiology of an epidural hematoma, what are anticipated responses of the patient to an epidural hematoma that is left-
sided?

2. what is the classic clinical picture of epidural hematoma? Are Mr. P's responses consistent with this diagnosis? Why or why not? What
additional data should be collected?

3. The physician is concerned about an uncal hernation. Describe this condition from a medical perspective. What observations should the
nurse make?

4. Discuss surgical and medical options for the patient. Compare these in terms of effectiveness.

5. Mr. P is sent for another CT scan. What actions by the technician could result in increased intracranial pressure? What actions by other
providers might increase intracranial pressure? Why?

6. What pharmacologic agents decrease cerebral edema for a patient with an epidural hematoma? How do these work?

7. As a group, plan care for Mr. P. How would you include occupational health?

These scenarios would be a valuable strategy for use in interdisciplinary seminars in which students from varied health professions discuss
patient care. Mitchell, et al. (2000) described problem-based seminars for students in health sciences. Analysis of critical thinking scenarios
in these seminars would allow students to appreciate how health professionals analyze patient situations, understand the unique contributions
of the provider to patient care, and learn how to work together as a team to solve patient problems.

Summary

In clinical practice, students are continually faced with patient problems as well as other problems to be solved. As students progress through
a health professions program, they need experience in learning how to solve these problems. Critical thinking ability is essential when faced
with problems that are not clear-cut and when multiple decisions are possible. Clinical scenarios are short cases with open-ended questions
that encourage development of critical thinking skills, bridging the gap between theory and practice.

References

Fuszard, B. (1995). Case method. In B. Fuszard, Innovative teaching strategies in nursing (2nd ed.), pp. 81-92. Gaithersburg, MD: Aspen.

Gaberson, K., & Oermann, M.H. (1999). Clinical teaching strategies in nursing education. New York: Springer.