Quandaries, questions, and queries:
A strategy for teaching clinical decision making
Jo Shackelford, M.A., CCC‐SLP & Lauren E. Bland, Ph.D., CCC‐SLP
Abstract
To encourage students to consider the rationale behind clinical
decisions, they were provided the opportunity to create decision-making
mazes using Quandary software. Students were given simulated cases
and questions regarding the management of the cases. They then created
decision trees, providing evidence-based rationale for several possible
courses of action at each decision point. Use of this interactive software
supported clinical decision making and was an effective way to engage
and motivate students. Using a tool such as this, instructors can help
students demonstrate the skills competencies mandated by the current
ASHA certification standards (ASHA, 2005).
Background
The challenge:
help students develop competency in numerous
clinical areas;
engage students in learning;
infuse more critical thinking activities into classes.
A Sample Decision Making Maze
Here's the situation:
You receive a
referral on a person
who is, according to
the charge nurse,
"having difficulty
eating." Your first
step will be to:
Ask the nurse to
write an order for a
dysphagia
evaluation.
Head for the
dining room and
screen the patient
during lunch.
You should
complete a
screening prior to
requesting an
evaluation order to
confirm that this is
an appropriate
referral. Go back.
Correct. Screening
is an appropriate
step to determine if
this is an
appropriate referral
for dysphagia.
Observation of the
patient and staff
interviews reveal
that the patient is
having difficulty only
in getting food from
the plate to her
mouth because of a
hand tremor. What
do you do next?
Request an order
for a dysphagia
evaluation.
Refer the patient
to Occupational
Therapy for
assistance with
feeding
techniques.
This patient is not
an appropriate
referral for you
because her
difficulty does not
involve
swallowing.
Go back.
Congratulations!
Document your
referral,
communicate it to
nursing and OT,
and you have
successfully
handled this case.
Summary and Future Directions
Observation and survey results indicate that the use of this computer-based
interactive tool supported clinical decision making and was an effective way to
engage and motivate students. Students provided constructive feedback to refine
and improve the teaching activity.
Student recommendations:
ƒ Give detailed written instructions and demonstrate on a large screen as they
move through the steps on individual computers;
ƒ Introduce the format of the activity early in the semester so it can be used
multiple times;
ƒ Use the activity as a quiz or homework;
ƒ Use only the paper and pencil format in class, and don’t require all students
to enter information into the software program due to complexity and time
efficiency.
A proposed solution:
use interactive software to support decision making in
multiple clinical areas. We used Quandary version 2 from
Half-Baked Software, Inc.
Method
Nineteen CD
graduate
students were
presented with
brief clinical
cases which
were developed
by an experienced
clinician.
They were then
asked to:
ƒ make a decision tree incorporating successive steps in the
assessment or management of a case.
ƒ develop one correct and several incorrect choices at each step in
the decision tree, along with supporting rationale.
ƒ use a pen-and-paper format, working in groups of two. This
allowed students to think through and discuss clinical decisions
without the added task of managing the new technology.
ƒ create a Quandary maze using the decision points and rationale
generated during the pen-and-paper task.
ƒ complete a written Likert-style survey designed to provide
feedback on the success of this learning task in supporting decision
making and engaging the student.
Figure 1. Sample brief decision tree for a dysphagia case. Correct responses lead to the
next situation (blue arrows). Incorrect responses (red) lead back to the decision point at
which the error was made (purple).
Findings
Did the use of Quandary support clinical decision making?
The decision tree creation process generated discussion of options and
supporting rationale at each decision point in the management of the clinical
case. It served as an opportunity for students to apply knowledge learned in
class. Most students (74%) agreed or strongly agreed that the Quandary task
helped them identify major decision-making points. Most students (84%)
agreed or strongly agreed that the activity helped them understand the
process of making good clinical decisions. Student quotes:
“Helps you to see the reasoning/rationale behind the decisions.”
“Helps to understand the steps to take when doing an evaluation.”
“It allowed us to think in depth about clinical decisions.”
Did the use of Quandary engage and motivate students?
Student engagement in the learning task was high, as indicated by
abundant class discussion, spontaneous peer-to-peer interaction and teaching,
and the high quality of the mazes produced. Most students (80%) agreed or
strongly agreed that they learn best by listening and processing information,
then completing a task for themselves . Most students (84%) indicated the
activity was beneficial. Student quotes:
“I work better with hands-on activities like this.”
“Allows you to interact with peers while completing the assignment.”
“Gives real-life situations.”
“Do more tasks like this.”
“The technology is complicated/confusing.”
“Too time consuming for an in-class activity.”
Future implementation will be modified based on student feedback. Mazes can
be loaded to course management systems (such as Blackboard) and university
websites for increased access. Future research might consider how student
learning style and course delivery options (such as distance learning) affect the
success of such a technology-based active learning exercise.
References
ASHA. (2005). 2005 Standards and implementation procedures for the certificate of
clinical competence in speech-language pathology. Retrieved November 6, 2009
from http://www.asha.org/certification/slp_standards.htm
Quandary, by Half-Baked Software, Inc., available at
http://www.halfbakedsoftware.com/quandary.php (free download, examples,
and tutorials)
Contact Information
Western Kentucky University
College of Health and Human Services
Department of Communication Disorders
Jo Shackelford, M.A., CCC-SLP
[email protected]
Lauren E. Bland, Ph.D., CCC-SLP
[email protected]
1906 College Heights Blvd. #11030, Bowling Green, Kentucky 42101-1030
270-745-4541
http://www.wku.edu/communicationdisorders
Acknowledgements
Thanks to the second-year graduate student class for their participation, and to Sally
Kuhlenschmidt, Ph.D., Director, Faculty Center for Excellence in Teaching (FaCET) for her ideas
and support on this project. Printed by Academic Center for Excellence.