The purpose of this module is to explore the concept of clinical judgment and its role in nursing education as well as the competency of nurses entering the profession.
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The purpose of this module is to explore the concept of clinical judgment and its role in nursing education as well as the competency of nurses entering the profession.
By the completion of this activity, the nurse will be able to:
- define clinical judgment for nursing students and graduate nurses
- explain the differences in critical thinking and clinical judgment for nursing students and graduate nurses
- explore the impact of clinical judgment on patient safety and outcomes
- consider how nurse educators can develop and assess clinical judgment in nursing students
- discuss the National Council of State Boards of Nursing (NCSBN) Clinical Judgment Measurement Model (NCJMM) and its impact on nursing education
The Nurse Educator Role in Developing Clinical Judgment
Nursing students and new graduate nurses entering the clinical setting encounter many challenges in delivering safe and effective care for positive patient outcomes. In recent studies, up to 23% of new graduate nurses did not demonstrate entry-level competency or clinical judgment in the same manner as their experienced counterparts (Kavanagh & Szweda, 2017). Poor clinical judgment can have profound negative consequences on patient outcomes, such as if nurses fail to promptly address subtle changes in a patient’s condition as they begin to deteriorate clinically. Nursing students and graduate nurses must be provided with focused training and clinical insight into promptly and appropriately identifying patient needs. This skillset requires knowledge about medical conditions and disease processes, the principles of medication administration, pharmacokinetics, and adverse effects, as well as the ability to appropriately apply this information to meet individual patient needs. Experienced nurses have acquired and developed clinical judgment through trial and error while delivering patient care. They may not recall or understand the acute learning needs of students trying to develop these skills. Due to the shortage in staffing and resources, new graduate nurses are expected to hit the ground running, delivering safe and effective care in a fast-paced healthcare environment that is saturated with high-acuity, high patient-to-nurse ratios, and complex clinical conditions. To ensure nursing students and new graduate nurses are prepared for these demands upon entering the clinical setting, recurrent application and intentional practice of clinical judgment must occur during their education. This module will discuss the importance of clinical judgment as defined by the NCSBN and the implications for nurse educators as they prepare the next generation of nurses (Rose, 2020).
Defining Clinical Judgment
While several terms are used interchangeably to describe the competencies needed to deliver safe and effective patient care, they have different meanings; educators should understand the distinctions among them to educate students appropriately. The following terms are interrelated and represent important processes that lead to the comprehensive application of evidence-based practice (EBP).
- Clinical judgment is the conclusion, decision, or opinion a nurse makes after they consider the issue, based on critical thinking or clinical reasoning.
- Clinical reasoning is the process used to consider issues at the patient’s bedside or point of care to prevent or manage a problem.
- Critical thinking is a broad term that includes reasoning inside and outside of the clinical setting (Alfaro-Lefevre, 2017).
Figure 1 shows the relationship between these terms.
There have been conversations on the use of critical thinking versus the nursing process by nurse education experts. The American Nurses Association (ANA) standards state that the nursing process serves as a critical thinking model that promotes competent care of patients (ANA, 2015). If the nursing process serves as a critical thinking model, then it is a tool for clinical reasoning as well as considering the correlation of these concepts (Alfaro-Lefevre, 2017).
Critical thinking, which leads to clinical reasoning and ultimately clinical judgment, is “purposeful, informed, outcome thinking that:
- is guided by standards, policies, ethic codes, and laws;
- is driven by patient, family, and community needs, as well as nurses’ needs to give competent and efficient care;
- is based on principles of the nursing process, problem-solving, and the scientific method;
- focuses on safety and quality, constantly re-evaluating, self-correcting, and striving to improve;
- carefully identifies the key problems, issues, and risks involved [while] including patients, families, and key stakeholders in decision-making early in the process;
- uses logic, intuition, and creativity and is grounded in specific knowledge, skills, and experience; and
- calls for strategies that make the most of human potential and compensate for problems created by human nature (e.g., finding ways to prevent errors, using technology, and overcoming the powerful influence of personal views).” (Alfaro-Lefevre, 2017, pp. 6-7).
In 1985, Benner first noted that critical thinking was based on attitudes and skills relative to logic, rationality, and reasoning (Benner et al., 2009). A person’s knowledge, skills, and attitudes (KSAs) drive their critical thinking. The Quality and Safety Education for Nurses (QSEN, n.d.) competencies, which focus on positive patient outcomes, highlight the importance of KSAs in student and graduate nurses. Table 1 shows the critical thinking opportunities that lead to clinical judgment.
A nurse able to utilize clinical reasoning qualities in the clinical setting:
- uses formal and informal thinking strategies to gather and analyze patient information;
- evaluates the significance of gathered information and weighs alternative actions;
- applies a cyclical process involving cue acquisition and analysis to take the appropriate action within the required time to facilitate positive outcomes;
- involves the ability to analyze, use logic, seek information, discriminate, apply standards, predict, and apply the knowledge; and
- must have effective communication skills plus an appropriate educational level, knowledge, and ability to think critically, along with a familiarity with the environment and context of care (Griffits et al., 2017).
Clinical judgment requires that critical thinking and clinical reasoning have occurred in the delivery of care. Tanner first described this concept in 2006 as “an 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” (p. 204). Tanner further develops a clinical judgment model from over 30 years of synthesis of research, incorporating four aspects of clinical judgment: noticing, interpreting, responding, and reflecting. According to this model, a nurse’s judgment in the clinical setting involves:
- a grasp of the clinical situation at hand and an awareness of it (noticing),
- interpreting the situation and determining how to respond (interpreting),
- deciding on an appropri
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ate course of action (responding),
attending to the patient’s responses to the action and assessing the situation (reflection), andreviewing the outcomes of the action while focusing on the appropriateness of all the preceding actions (reflection; Benner et al., 2009; Billings, 2019; Tanner, 2006).Impact on Patient Outcomes
The quality of patient care depends on nurses who are prepared to recognize their needs and respond accordingly. Nursing judgment is directly related to the ability to apply EBP and to react to changes in the patient’s condition. Hospitals have recognized the lack of student preparedness for years and implemented extended orientations, preceptorships, mentoring programs, and nurse residency programs. The transition from novice nurse to practice is filled with insecurities, a lack of knowledge, and a deficit of clinical judgment. Both patients and medical facilities benefit from nurses who can demonstrate competent clinical judgment. Lasater and colleagues (2015) found that only 13% of preceptors believed novice nurses could establish priorities and demonstrate safe nursing care. High-quality patient care depends on the nurse’s competence and application of clinical judgment (Lasater et al., 2015). The NCSBN targets optimal outcomes for patients, nurses, and clinical organizations. Nurses should enter practice with the ability to make appropriate clinical decisions through clinical judgment (NCSBN, n.d.b).
Nurse Educator Role
A nurse educator’s role is to ensure nursing students deliver safe and effective care under their guidance. Clinical nurses may take several years to exhibit clinical competence and a high level of clinical judgment that leads to positive patient outcomes (Lasater et al., 2015). Tanner’s research indicates that regardless of education, experience is the greatest indicator of clinical judgment, particularly within specialty care areas such as intensive care (ICU) or obstetrics (OB): nurses with between three and six years of experience demonstrate the highest levels of clinical judgment (Lasater et al., 2015; Tanner, 2006).
So, without years of experience, how can educators ensure students are clinically competent and possess accurate clinical judgment? Starting from a student’s admission to a program, educators should be assessing the student’s KSAs. During a program, individual activities should be intentionally developed to hone the student’s critical thinking and clinical reasoning skills. These modalities serve to establish and develop clinical judgment and competency for when they graduate and enter clinical practice. A lecture alone will not enable students to attain these vital clinical skills, nor will random clinical experiences. Teaching students how to develop their own clinical reasoning and judgment is complicated, and learning the skill is equally complicated (Billings, 2019; Lasater et al., 2015).
As previously discussed, experienced nurses have an internalized ability to assess, apply knowledge and intuition, provide intentional thought in a situation, and collaborate with their peers and healthcare team to deliver safe and effective care. How did these abilities form? In response to the information that new graduate nurses were not meeting the minimum expectations for safe and effective care upon entry into practice, the NCSBN generated a task model to measure clinical judgment. This model is used to frame the teaching and evaluation of the complex skill of clinical judgment. The NCSBN is further developing test items to evaluate prelicensure students’ ability to make safe and accurate clinical judgments. These test items will be added to the National Council Licensure Examination (NCLEX) test plan during the 2022–2023 testing cycle. Before developing these test items, the NCSBN developed its clinical judgment measurement model, the NCJMM. Nursing educators must be prepared to facilitate students’ competency in this skill to ensure their abilities in the clinical setting and promote success on their licensing examination (NCSBN, n.d.b).
NCJMM
Currently, test questions are based on the nursing process or Tanner’s model of clinical judgment in nursing, but neither foundation fully embraces the complexities of current nursing practice in the clinical setting (Billings, 2019). Future test items will also utilize the NCJMM as a guideline for assessing competency in new graduate nurses and their ability to function in the clinical setting. The NCJMM was created by researchers from the NCSBN as a “framework for the valid measurement of clinical judgment and decision making within the context of a standardized, high-stakes examination” (NCSBN, n.d.a, para. 1). This model does not redefine clinical judgment but gives the NCSBN and nurse educators a method for measuring and deriving inferences around clinical judgment and the ability of entry-level nurses to make decisions that are safe and effective for positive patient outcomes. Six steps within this model help define the process of clinical judgment. These steps are:
- The nurse must recognize cues.
- The nurse must analyze the cues.
- The nurse must prioritize hypotheses.
- The nurse must generate solutions.
- The nurse must take action.
- The nurse must evaluate outcomes (Billings, 2019; NCSBN, n.d.a).
Developing Clinical Judgment in Students
Educators can use these steps to facilitate learning through prompts that elicit behaviors from the learner as the judgment model unfolds. Prompts consist of questions that are used for teaching rather than as evaluations like most questions are. Excellent opportunities for practicing these steps occur through the development of experiential learning activities such as simulations. Experiential learning focuses on what the learner does and how they reflect on the activity they performed. Lessons should be developed that create an environment of safety and allow the students ample opportunities to practice and reflect on their learning of a specific activity. An example would be managing a central intravenous access line. Faculty may have developed a scenario where medications must be pushed, dressing changes must be performed, or the line must be discontinued. Students should practice performing the manual pieces of this skill but also managing care when issues arise. This would require the educator to develop several scenarios with various prompts and cues that could lead to the development of clinical judgment in a safe environment outside of actual patient care (Gaba, 2015). Billings (2019) offers several ideas for developing prompts for clinical judgment tasks, as noted in Table 4 below.
These types of prompts are used to facilitate learning and clinical judgment and not for evaluation or punitive reasons. The student should be aware of the purpose of this interaction to decrease anxiety. The prompts can be used during any type of learning, including a review of case studies, lab or simulation exercises, or clinical activities. The student should be given sufficient time to respond to the cues before follow-up, feedback, or corrections are given. The educator should clarify any misunderstandings or errors in judgment at each step of the model. This not only aids in the development of clinical judgment but also encourages patient safety (Billings, 2019).
Assessing Clinical Judgment
Now, a question arises regarding how to assess clinical judgment. Educators are likely thinking, “how do I know when my student is competent?” With multiple-choice questions, there is a right and wrong answer with distractors as the other options. With select-all-that-apply questions, there are one or more options for the student to choose, and the others are wrong. Attempting to evaluate clinical judgment can make writing tests and assessing responses more complex. For the development of test items within the NCLEX, teams of subject matter experts (SMEs) write scenarios. This step is followed by a rigid process to determine validity, but the educator in a classroom likely has fewer resources to develop methods of assessment for their students. Betts and colleagues (2019) note a step-by-step process for scenario writing to assess clinical judgment that includes the following sequence:
1. Develop a common clinical scenario that an entry-level nurse could be expected to encounter and would be appropriate.
2. Describe or list the facts/observations and note the context within which the problem presents.
3. Review the current information (shift handover reports, patient history reports, laboratory results, etc.) and gather new information where needed.
4. Interpret cues to understand the situation and the presenting signs or symptoms:
a. distinguish between normal/abnormal,
b. distinguish between relevant/irrelevant information, and
c. evaluate clusters of symptoms.
5. Synthesize facts and make inferences to generate a hypothesis or a set of possible hypotheses regarding the patient problem and prioritize the set (e.g., ranking by most plausible to least, most important to address now vs. later).
6. Formulate a course of action:
a. identify a set of possible interventions to alleviate the presenting issue or
b. select the best alternative(s) from the set of possible options.
7. Evaluate the effectiveness of the intervention (e.g., what would a positive/negative outcome look like, how would you know the intervention was effective).
8. When writing distractors, think about common errors made by entry-level nurses relative to each clinical judgment element (Betts et al., 2019, p. 28).
Additionally, the items should be scaffolded based on the steps of the nursing process: assessment, nursing diagnosis, outcomes/planning, implementation, and evaluation. Item writing to determine clinical judgment may result in various types of questions such as multiple responses (select all that apply), hot-spot or highlighting information, drop-down menus with options, and drag and drop options, as well as the use of a matrix or grid. Formal clinical judgment assessments take time and should be slowly integrated into the testing of a program. Just as the NCLEX has slowly introduced clinical judgment questions into exams through volunteers, an individual nursing program can incorporate scenarios with questions as pilots to determine validity while introducing students to alternative methods of assessment (Betts et al., 2019). For more information on the development of items for examinations, go to ncsbn.org and the NCJMM page and review their resources for educators (NCSBN, n.d.a).
References
Alfaro-Lefevre, R. (2017). Clinical reasoning and clinical judgment: A practical approach. Elsevier.
American Nurses Association. (2015). Nursing scope and standards of performance and standards of clinical practice. American Nurses Publishing.
Benner, P., Tanner, C. A., & Chesla, C. A. (2009). Expertise in nursing practice: Caring, clinical judgment, and ethics. Springer Publishing.
Betts, J., Muntean, W., Kim, D., Jorion, N., & Dickison, P. (2019). Building a method for writing clinical judgment items for entry-level nursing exams. Journal of Applied Testing Technology, 20(S2), 21-36. https://www.ncsbn.org/Building_a_Method_for_Writing_Clinical_Judgment_It.pdf
Billings, D. M. (2019). Teaching nurses to make clinical judgments that ensure patient safety. The Journal of Continuing Education in Nursing, 50(7), 300-302. https://doi.org/10.3928/00220124-20190612-04
Facione, P. (2020). Critical thinking: What it is and why it counts (2020 update). https://www.insightassessment.com/wp-content/uploads/ia/pdf/whatwhy.pdf
Gaba, A. (2015). Teaching clinical judgment: A review with consideration of applications for health professions. The Open Nutrition Journal, 9(Supplement 1-M7), 53-64. https://doi.org/10.2174/1876396001509010053
Griffits, S., Hines, S., Moloney, C., & Nicholas, R. (2017). Characteristics and processes of clinical reasoning in nurses and factors related to its use: A scoping review protocol. JBI Database of Systematic Reviews and Implementation Reports, 15(12), 2832-2836. https://doi.org/10.11124/JBISRIR-2016-003273
Kavanagh, J., & Szweda, C. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses’ clinical reasoning. Nursing Education Perspectives, 38, 57-62. https://doi.org/10.1097/01.NEP.0000000000000112
Lasater, K., Nielson, A., Stock, N., & Ostrogorsky, T. (2015). Evaluating the clinical judgment of newly hired staff nurses. The Journal of Continuing Education in Nursing, 46, 563-571. https://doi.org/10.3928/00220124-20151112-09
McCartney, M. (2017). Nurses must be allowed to exercise professional judgment. BMJ, 356, j1548. https://doi.org/10.1136/bmj.j1548
National Council on State Boards of Nursing. (n.d.a). NCSBN clinical judgment measurement model. Retrieved September 10, 2020, from https://www.ncsbn.org/14798.htm
National Council on State Boards of Nursing. (n.d.b). Next generation NCLEX project. Retrieved September 11, 2020, from https://www.ncsbn.org/next-generation-nclex.htm
Quality and Safety Education for Nurses. (n.d.). Graduate QSEN competencies. Retrieved September 11, 2020, from https://qsen.org/competencies/graduate-ksas/
Rose, K. (2020). Creative tips for teaching clinical judgment. https://www.wolterskluwer.com/en/expert-insights/creative-tips-teaching-clinical-judgment
Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. https://doi.org/10.3928/01484834-20060601-04