Using intentional forced errors to build clinical judgment

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Lauren continued, tone light but measured. Back when I worked
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in the PICU, we had a charge nurse who was exacting, brilliant,
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but calculated. She had very high expectations of everyone, and
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God help you if you didn't measure up. If she
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felt you were underperforming, she didn't yell, didn't file complaints.
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She just turned up the pressure, always made you feel
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like you were being watched, measured against her yardstick. Lauren
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paused a moment and then went on. And eventually, you'd
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mess up. Small things, mostly. A misdose, a mischarted allergy,
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but just enough to reinforce the belief that you were
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not good enough. We used to call them forced errors.
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She said it evenly, like it wasn't just a term,
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but a diagnosis. Not mistakes, just traps, set just right.
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What happens when fiction becomes a powerful teaching tool? Dr.
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Annette Severson shares how storytelling can push nursing students beyond
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checklists into real clinical thinking. Welcome to Lip and Cot Spark,
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Illuminating Nursing Education, the podcast that fuels teaching, innovation, and leadership.
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I'm Dr. Kelly Dries. Each episode, we spotlight bold ideas,
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expert voices, and practical strategies to help you teach smarter,
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lead stronger, and stay inspired. Let's spark new thinking and
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dive into today's episode. What if errors in healthcare weren't
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always accidental? And what if learning to recognize them could
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fundamentally change how nurses think, lead, and advocate for patient safety?
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In today's complex clinical environments, nurses are making high stakes
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decisions inside systems that don't always work the way we
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expect them to. In today's episode, we're gonna explore how
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intentional discomfort, storytelling, and systems thinking can spark deeper clinical
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judgment in nursing students. Joining us is Dr. Annette Severson, nurse, scholar,
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and author of the medical suspense novel, Forced Errors, Not
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All Errors Are Unintentional. Drawing on her critical care background
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and her narrative immersion theoretical framework, Annette challenges us to
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rethink curriculum design, assessment, and how we prepare nurses to
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navigate complex, high-acuity systems, especially when the right answer isn't obvious. Welcome, Annette.
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Well, thanks, Kelly. I'm so glad to be here and
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to have the opportunity to share something that's really garnered
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my attention over the last nine, 12 months and a
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And so I'm really pleased to be here and share
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this with you and your listeners.
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So I'd love to set the stage for our listeners.
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What gaps do you see between how nursing education prepares
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students in the classroom and really what they're actually facing
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in this complex kind of unfolding clinical practice?
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Well, you know, that's the question that plagues most nurses, right?
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It's like, how do we get better? I don't think
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that the primary gap is informational or procedural. I think
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that as nurse educators, we're very effective at teaching skills
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and procedures. That students become very good at learning those, right?
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Because that's what their vision of being a nurse is.
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It's all about the skills. I think the gap is
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more interpretive. So understanding how to continually reassess and apply
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those skills in clinical environments where you said that the
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contextual variables are constantly changing. as a new piece of
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information becomes suddenly available, a decision that felt appropriate just
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a moment ago, now all of a sudden feels incomplete
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or obviously wrong. And there isn't always an obvious next step.
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And that's, I think, what trips students up. And honestly,
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I think that challenge exists for nurses in practice and
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those moving into leadership roles as well, because they haven't
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had the opportunity to get good at identifying those important
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contextual variables that And are not practiced at making sense
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of them in real time. They do what we taught
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them to do, but yet new grads continue to report
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that they feel uncertain when they're navigating in that clinical space.
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And I think it's an important adjudicational gap that, you know,
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we should pay attention to and see if we can't,
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through innovative strategies, maybe close that gap for our new
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grads and those moving into new roles.
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So you authored this extraordinary, I'm going to say, because
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I read it cover to cover, I couldn't put it down,
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this medical suspense novel called Forced Errors. And I'm just wondering,
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what led you to begin exploring fiction? as a way
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to engage nursing students in deeper critical thinking?
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Well, to be honest with you, I actually didn't start
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writing with the idea of using fiction in nursing education.
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It really began for me after I finished Forced Errors.
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I asked a friend, Anne, who's not a nurse, not
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in healthcare at all, and a colleague of mine, Alex,
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who's a practicing bedside nurse, I asked them to be
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my beta readers. So to read it through and give
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me feedback about the story. And what fascinated me was
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how differently they each interpreted the same story. They identified
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different moments as important. They trusted or distrusted characters differently.
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Even the timing of their conclusions about what was going
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on was different. And it wasn't that Anne was wrong,
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but it was clear that the things that resonated for
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her were quite different from the things that Alex found
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meaningful or that she pointed to as purposeful in the story.
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So that got me thinking about how novice nurses interpret
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their clinical environment. We all know students enter with very
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different internal frameworks for deciding what matters and what feels
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urgent to them and what they question. And so I
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started wondering whether narrative immersion, different from like a traditional
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clinical rotation environment, might create a more reflective and structured
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environment for helping students refine how they interpret those clinical situations.
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And I think while simulation and unfolding case studies begin
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to address that, the long format fiction may offer something
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slightly different in that the sustained narrative, those subtle details
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are intentionally withheld, right? And the clues are revealed over time.
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And it encourages a certain curiosity. that's necessary to move
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beyond the, you know, what do I do next to
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how does this next thing make sense in this situation?
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And that concept really felt powerful to me. Like we
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can do something with that. Yeah.
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Stories are powerful, right? When you hear a story, it's like, wow,
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that really sticks. And Your novel shows how systems, not
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just individuals, it really shapes those outcomes. And you just
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mentioned our nurse educators and leaders who listen to this podcast,
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many of them use those traditional case studies or unfolding
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case studies and checklists to kind of change the way
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students think. But stepping into a story, I'm wondering how
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can narrative immersion change help them develop system thinking, like
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that clinical judgment and the ability to recognize when errors
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are essentially being set up. And how do they even
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know they're being set up? Because when I went into nursing,
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I thought, you know, the electronic health record should be perfect, right?
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There shouldn't be errors in it. And, you know, the
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processes and the checklists, everything should be on point. But
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in reality, it's not. So how do we identify those
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And really recognize when those errors, you know, are essentially
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being set up by the system.
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Well, I think your question is sort of centering on
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changing the way students think, presumably to be more mindful
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of systems thinking and error prevention. I think that's kind
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of what we're circling around. And I don't think storytelling
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or the use of story replaces traditional teaching strategies like
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case studies or simulation because they do target those specific skills.
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But I do think that narrative emergent has a different
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kind of engagement. And an unfolding case study usually asks
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the students, what would you do next? I think story
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tends to ask, what do you think is really happening here?
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So providing the context. And that matters because clinical practice
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is rarely static and sometimes it's really just, it's unpredictable.
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And we're trying to constantly understand what's happening and why.
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In many ways, good suspense fiction actually mirrors advanced clinical reasoning.
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So as readers, we naturally start following the explanation that
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seems most reasonable based on the information that the author
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has presented us. But we also stay open to the
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possibility that something else may be going on because the
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details just don't line up. That's really a good suspense story.
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It keeps you on the edge. There's a common saying
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in medical training, if you hear hoofbeats, think horses, not zebras.
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Have you heard that one? Yeah. And it's essentially saying
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that the most likely answer is likely the correct answer.
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And that's important because I think we do have to
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think in terms of probability. But strong clinicians don't completely
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dismiss the zebras, right? They continue to reassess the situation
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as new information emerges, and they don't close their interpretation
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too quickly. And I think that's what narrative immersion may
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offer students is the opportunity to practice making sense of
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the situations before the meaning or before that next best
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step becomes obvious to them. There's actually a scenario in
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forced errors where a manager during a performance review tells
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a nurse, you're doing a great job. but I need
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you to take more initiative. And the nurse generally tries
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to rise to that expectation. She becomes more proactive. She
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starts independently adjusting aspects of care. And she reduces the
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fall precautions when a patient appears to be more stable
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but hasn't yet fully recovered. And what's interesting about that
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situation is that the nurse wasn't careless. She wasn't really uninformed.
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But she's acting on her interpretation of the direction that
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she was given by an authority figure and trying to
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function more independently. So I think that's where immersion in
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the narrative becomes more educationally powerful because students can now
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slow down. They can examine all those layers. What assumptions
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were made? What did that nurse prioritize in the moment?
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How did the communication with the manager shape her thinking?
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because they just read the whole exchange and they get
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the whole picture. So, you know, I think those dynamics
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are difficult to put into a case study that's generally
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pretty short, but within the complete story, you get to
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experience how those judgments were made. And I think that
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ability helps you understand more of the interconnectedness of those
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systems pieces that really do affect our practice.
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And identify those zebras, right?
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Yeah, yeah.
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Possible zebras. So assessment often drives learning. So how can
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educators use tools like standardized rubrics or structured reflection to
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meaningfully assess what students are learning through narrative immersion? Because
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at the end of the day, we need to assess
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the learner, right?
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Right. And that also tells us how effective we're being
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as faculty members. So no, assessment is critical. And I
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guess in my mind, I don't really see narrative immersion,
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the assessment of learning that happens during narrative immersion to
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be all that different from simulation. Because, you know, I
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think that it's that they both require that debrief afterwards,
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that learning activity where you do structured reflection and guided
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discussion afterwards is really where the learning occurs. I think
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it's for narrative immersion, in my mind, it's more about
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the engagement. It's more a different way of engaging the student. So,
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you know, I think that the learning outcomes can absolutely
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be aligned with the professional standards and assessed through structured rubrics,
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just much along the novice to expert continuum that we're
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already using. So I guess I don't see the assessment
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of learning to being different. I see the vehicle that
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gets them to the learning to be the difference.
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You know, and we try to use different kind of multimodal,
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different types of strategies to be able to relate information.
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And we see, you know, our faculty using the case
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studies and simulation and podcasts and a lot of different
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strategies in the classroom, you know, right now.
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Learners learn differently. Different people, you know, resonate. A story
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will resonate with someone. Someone will say, oh, this is boring.
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A simulation, unless you don't, if you can't get them
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to suspend their reality for a minute, like if they're
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just so, you know, ingrained in the moment, you know,
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they might not flip into that space where simulation really
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engages you emotionally and physically. And so we do, we
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do have to appreciate that different learners, that learners learn differently.
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And there are many modes to get us there.
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So I think about beyond cognition, you know, students are
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also forming confidence and their professional identity as well. So
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how does engaging with stories like forced errors help learners
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think differently about the staffing pressures? So when I read this,
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I thought, wow, there's a lot on staffing pressures and
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teamwork and navigating those power structures and where's my place
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and should I speak up or should I remain silent?
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How is, again, kind of these stories like forced errors
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helping increase confidence and form that professional identity as they
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emerge as professionals in nursing?
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I think the question points to the idea that perhaps
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students and even faculty may underestimate the influence of the
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work environment, the influence that the work environment has on
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our practice. One of the unique things, I think, about
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a sustained narrative immersion is that students begin to experience
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the healthcare experience. as interconnected rather than in isolation. I
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think traditionally faculty tend to share those learning concepts or
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those concepts like staffing pressures and communication and breakdown hierarchy
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in separate concepts and in separate learning modules, right? Here's
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this chapter on HR issues and here's a chapter on- Kind.
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Of siloed, right?
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Yeah, they're just compartmentalized. Yes, yes. But we know in
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practice that those schmooey together and cause problems most often.
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in the story, in Forced Errors, I think learners are
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able to see how reasonable people can gradually adapt to
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system pressures without themselves fully recognizing it, but the students
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see it as it happens. And they begin noticing how
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staff concerns influence communication, how hierarchy shapes when someone speaks up,
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how workflow pressures affect decision-making, and this notion that errors
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are not caused by one individual mistake. It's that cascading
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of small interpretations and adaptations that accumulate over time. And
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I think that's important for emerging professionals because many new nurses,
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when they enter practice, they believe that clinical situations are
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primarily about individual knowledge and correct actions. If I just
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know the right thing to do, I'll be okay. But
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they haven't become aware of how relational and systems-based our
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health care systems are. In forced errors, there's a scenario
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where a nurse is covering for a colleague's meal break,
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and she walks into the patient's room, and there's an
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antibiotic hanging, but it's not infusing yet. And so everything
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about that situation appears really normal and complete. So she
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begins the antibiotic infusion without independently verifying the medication. What's
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important about that situation is that the nurse absolutely knows
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the five rights or six rights, however you teach it,
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of medication administration. They know that. The issue isn't a
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lack of knowledge. It's that the surrounding workflow and context
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subtly communicate that the necessary thinking has already been done.
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Somebody already solved this problem. I just need to start
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the infusion. And I think what it allows learners to
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do is to examine those pivotal moments more carefully. So
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why did that situation feel safe? What assumptions were operating?
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At what point should she have re-verified the medication? And
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being practiced at answering those kinds of questions, I think,
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is way more valuable to students than simply reminding them
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to you know, follow the hospital policy.
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You know, Annette, this reminds me of the NCSBN clinical
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judgment measurement model, kind of that layer four, where the
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environmental factors really impact a student's ability to make decisions.
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And it provides that contextual elements like those time pressures
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and the complexity of the tasks and Also, the individual
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factors as well, you know, the knowledge that they bring
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to the table and the skills that they have. Annette,
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educators are often asked to innovate with limited proof points.
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What might a proof of concept look like for integrating
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narrative immersion into a nursing curriculum? And I'm wondering how
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could nurse educators partner with you to explore the effectiveness
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of this strategy?
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As I've been thinking about this, I was thinking about
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about it on a continuum, that on one end of
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the continuum, that forced errors would become the textbook, if
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you will, and then faculty would supplement that with research
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or theories or readings to round out the learning objectives.
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And then on the other end of the spectrum, I
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was thinking that the novel could be used as a
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companion to a current leadership textbook. But then one of
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the things that surprised me was how naturally even a
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very short narrative segment aligned with existing leadership concepts. I
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recently mapped chapter three, which is my favorite chapter, that's
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just over 1,200 words, against Houston's nursing leadership textbook. And
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I found that in that single chapter, nearly 50% of
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the content in Houston's table of contents were touched on
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just by reading that one chapter. And so that really
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sort of changed my thinking that this doesn't have to
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be a wholesale curricular change in order to begin experimenting
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with narrative immersion. Now I'm thinking that really could start
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as simply using a single chapter that aligns to one
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of a hundred different learning objectives you have in your
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course or that the faculty member has in their course
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And use the rubric or use whatever. your current measurement
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of skill attainment is and see if it makes a
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difference and see if students don't report feeling like I
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was more engaged or this felt more real to me,
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those kinds of things. I feel like I can now
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use that going forward in my practice. So Yeah. So again,
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in the beginning, I thought it had to be a
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wholesale change. Now I don't think so. Now I think
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it can be very incremental. And so I am very
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interested in working with my colleagues who feel like there
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is a potential benefit for using narrative immersion in their
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coursework or in their professional development offerings. If we have
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faculty out there who have a master's student or a
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doctoral student who needs a project, that would really be
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something I'd love to collaborate on as well. And so
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I see a wide range of opportunity here, and I'd
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love to just speak with like-minded people who want to
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explore something different.
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That would be great. How would they get a hold
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of you, Annette, if they want to do that?
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Yeah, yeah. I think the best way is I have
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a separate author email apart from my personal email. And
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so my author email is AnnetteSeversonAuthor, all together, at gmail.com.
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And so, yeah, I'd love to hear from people.
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Yeah, that would be fantastic. And just touching on, you
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mentioned Dr. Carol Houston, who also was on this podcast.
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She's a Lippincott author. And like you said, to be
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able to take this and link it to some of
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those leadership components is definitely of interest as well. So
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if you could leave our listeners with one spark, kind
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of a pearl of wisdom or a call to action,
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what would you encourage nurse educators to try?
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I think if I had one spark, it would probably
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be to create opportunities for students to use their curiosity
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a little bit longer before rushing them to an answer.
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I think we're really good at teaching students what to do.
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The challenge, I think, is helping them practice making sense
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of complex situations when the answers aren't immediately obvious. And
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so that's whether it's through narrative immersion or simulation or
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reflective discussions or some other strategy. I think there's real
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value in helping students develop a curiosity and that I
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think it helps them move their practice in a really
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different way, even though it might feel uncomfortable for the faculty.
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Because I think if ultimately if we want students to
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think differently, you know, we might have to teach differently.
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Thank you so much, Annette, for challenging us to think
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differently about how we teach clinical judgment and systems thinking
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and leadership in nursing education. And I'm excited for our
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listeners to teach. Like you said, those students, if we
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want them to practice differently, they have to teach differently.
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So by embracing innovation and the power of storytelling. So
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thanks again, Annette.
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Thank you so much.
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Thanks for listening to Lip and Cot Spark. Be sure
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to subscribe, share with a colleague, and leave us a
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five-star review. You'll find links below to learn more about
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Lippincott Nursing products and services. Until next time, keep learning,
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keep leading, and keep sparking innovation in nursing education.