The "What Can Go Wrong?" pediatric clinical evaluation tool was adapted from a tool developed by the third author (Dr Caputi), whose work was influenced by the concepts delineated in Tanner's1 writing on clinical judgment. We use the tool to assess and promote critical thinking for students in a child nursing course. The tool directs the student to consider what could go wrong for an individual patient and the family. It addresses 2 problems frequently encountered in students' thinking. First is the student's tendency to simply consider existing problems when there is a need to anticipate problems that have a high probability of occurring. Second is the frequent inability of students to tailor nursing care to each individual and family. The 1-page tool is used as a quick clinical assessment to provide information about a student's clinical judgment. Figure 1 shows the tool's questions.
Tanner1(p204) defines clinical judgment as the "interpretation or conclusion about a patient's needs, concerns or health problems and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response." This definition provides important outcomes of critical thinking: developing the ability to individualize care and develop clinical judgment. Both of these outcomes are embedded in the pediatric tool.
Our experience has been that students learn the nursing process well and grow in their ability to recognize problems but fall short in identifying all the potential concerns lurking in the patient's situation. Even more difficult for the student is to recognize that there may be potential problems in the family of the pediatric patient. Students also consistently have difficulty individualizing care. They use generic interventions without consideration of adaptations for a specific family or the developmental needs of the pediatric patient. The tool asks the student to identify the essential assessments for the patient and family on a particular day. Next, the students must identify what complications may occur for the child and what are the worst things that might happen during their assigned time with the child and family. Students are then asked to identify interventions to prevent these potential problems. Finally, the student must determine the 2 most important developmental concerns for the child during the hospitalization and interventions that could address these in the clinical situation.
The What Can Go Wrong? tool meets the criteria of a classroom assessment technique as defined by Angelo and Cross.2 As a classroom assessment technique, the tool can provide immediate feedback and clarify thinking on the clinical unit, which allows the student to reflect on the analysis of the clinical situation and the needs of the child and family. The students benefit by receiving and being able to immediately apply faculty feedback to hone their skills in individualizing care and anticipating potential concerns for the child and family members. Throughout the discussion, the highest standards of pediatric nursing care can be reinforced. As a clinical tool, it also provides an opportunity for faculty to determine how students think on their feet, with less reliance on others for assistance. The tool is flexible enough to be used in one-on-one consultation or in a group discussion in a clinical conference.
The tool has been helpful for students to apply basic principles that they frequently forget when they consider patients with complex pathology. For example, when caring for a child with the application of an external fixator, the students focused on the device and infection but not on the decrease in mobility and basic postoperative oxygenation concerns, whereas a student caring for a child with a spinal cord injury did not anticipate the potential occurrence of autonomic dysreflexia. Student completion of the tool allowed the teacher to identify these areas of deficiency in the student's thought process and provide the needed feedback to help the student critically think about the patient situation.
After using the tool for a short time, we found that the question "What is the worst thing that could happen?" often resulted in the student answering "the child could die." Although clearly the "worst thing" that could happen, it was an improbable outcome for the day based on the patient's condition. Students needed to be directed to think of the most realistic worst thing that could happen and anticipate and intervene to prevent that. Students also had difficulty identifying the needs of the family. They focused on the ill child. Faculty needed to help students think of the "patient" as the "family unit" and determine how they could anticipate needs and intervene. Lastly, the developmental assessment aspect of the form was not perceived by students to be as important as the physical symptoms of the illness. They had difficulty identifying developmental concerns, especially of older children. To assist students with this, we added a small table with 2 columns and 2 rows immediately after the developmental assessment question that asked them to identify 2 developmental concerns with a corresponding intervention.
Overall, the What Can Go Wrong? tool helps students to anticipate, recognize, and respond to patient conditions in the clinical setting. It helps students identify necessary assessments and possible complications. Faculty can quickly evaluate students' knowledge of expected assessment findings, ability to prioritize and individualize care, and critical thinking abilities. The quick assessment tool allows faculty to provide immediate, focused feedback for the students. The student response is positive, with students indicating that this tool "makes them think." Evaluations reflect that students believe that their critical thinking skills are being developed, they understand the importance of sound nursing judgments, and they are being challenged through the use of this tool.
Developing critical thinking is an ongoing process. Activities such as this "provide a venue for this ongoing process with the end goal that critical thinking will become intuitive and routine."3(p718)
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