Clinical decision making, clinical reasoning, and clinical judgment are all terms used to describe the complex cognitive work of nurses in patient-care settings.1-4 The National Council of State Boards of Nursing (NCSBN) defines clinical judgment as “the observed outcome of critical thinking and decision making. It is an iterative process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.”5
Sound clinical judgment is an essential skill used in more than 46% of tasks routinely performed by nurses in their first year of practice.6,7 There is a growing concern that novice nurses, who pass the NCLEX-RN, do not actually have the knowledge, skills, or cognitive abilities to practice safely.4,8-12 One study found that only 23% of newly graduated nurses demonstrated beginning-level competencies.9 Another study found up to 75% of novice nurses were involved in a medication error.10 Poor decision making may be the root cause of many nursing errors. Research suggests that up to 65% of adverse patient events could have been prevented if nurses had engaged in better decision making,4 yet only one-fifth of employers think their new nurse hires have satisfactory decision-making skills.12
Faculty are challenged to teach clinical judgment skills and evaluate students' ability to make effective clinical decisions. Tanner1 originally concluded that what nurses bring to a situation often influenced their clinical judgment more than the data at hand.1,13 A systematic literature review found that certain educational strategies could improve clinical judgment by improving what the nurse brings to the situation.13 Some of the teaching strategies found to facilitate the development of clinical judgment included using a model or framework, high-fidelity simulation with debriefing, exposure to concept-based learning, and the use of case studies.13 Similarly, an integrative review found that active learning strategies such as think-aloud case studies, simulations, collaborative group learning, clinical practice, and reflection promoted the development of clinical reasoning.14
Using a framework and guided discussion strategies may be a particularly effective way for educators to help students develop clinical judgment skills.14-17 Clinical judgment frameworks with consistent language serve as tools to objectively develop and measure clinical judgment.14 One integrative review found using a structured framework to teach clinical reasoning yielded positive findings in contrast to studies that did not use a framework.14
NSCBN Clinical Judgment and Task Model
When the NCSBN began the monumental task of determining if the licensure examination really measured the competencies needed by entry-level nurses, now known as Next Generation NCLEX (NGN), the project began with the development of a clinical judgment model (CJM) to guide the creation of new examination item prototypes for use in future test plans.18-20 The NCSBN- CJM was developed as an integrated decision-making framework with 4 layers. It is built on the foundation of context and includes well-defined reasoning steps focused on the discipline specific aspects of decision making.19,20
Together NCSBN-CJM layers 3 and 4 form the Task Model.19,20 Layer 4 is factoring conditions or context.20 The model affirms that the work of the nurse is complex. The appropriateness of any decision is contingent upon the combination of individual (internal) and environmental (external) factors that make up the case, situation, or scenario. Factoring in context, the nurse begins to make clinical judgments using the 6 cognitive processes of layer 3: recognizing cues, analyzing cues, prioritizing hypothesis, generating solutions, taking action, and evaluating outcomes.19,20 The Task Model is of importance to educators because the steps can be taught in class or clinical practice.19,20 Educators can assess if the expected actions or behaviors occur at each clinical judgment step to determine the correctness of a student's thought processes.19 These steps can also be measured through well-written items on objective tests.5 Educators can anticipate that new question types to measure clinical judgment will be implemented at some point after the unveiling of the next NCLEX test plan. These item types may include extended multiple response, hotspot/highlighting, drop-down, matrix, and extended drop-and-drag items.5
Curricular Integration of a CJM
The first step of curricular integration is for a program to select a CJM.15 Teaching clinical judgment skills using a single framework across the curriculum increases the opportunity to use the model with each simulated or actual patient encounter while integrating new content and concepts.14,15 Using the NCSBN-CJM has the advantage of preparing students for understanding the distinct, yet sequential clinical judgment steps and offers a template for subsequently designing assessment activities and test questions that may also better prepare students for the future NCLEX-RN.5,19,20
At the course level, faculty should use active strategies that include opportunities to observe students' thinking. The teaching strategy, in addition to operationalizing a CJM and providing sufficient context, should also take into consideration the level of the student in the curriculum, the scope of the content the student is expected to apply, the learning outcomes to be attained, and the opportunity to integrate and build on the knowledge, skills, and abilities of the student. Students may be better at some clinical judgment skills, such as recognizing cues, than others, such as taking action.21 To develop all skills, it is important for educators to plan to use the full CJM within a reasonable time frame.
Teaching Clinical Judgments With Clinical Scenarios
Clinical judgment can be effectively taught through class discourse.19 Clinical scenarios, cases, integrative cases, simulations, and unfolding case studies are representations of actual or contrived clinical situations that can be used for classroom discussion to provide students an opportunity to apply knowledge and link classroom learning with clinical practice.22-24 Clinical scenario is a term frequently used in simulation that refers to an outline of a patient encounter created by an instructor, which includes context and potential course of events.25 Clinical scenarios, as specifically used in the NCSBN Task Model and test item development, are designed as a clinical situation that entry-level nurses would encounter in their workplace.5 These scenarios include a description of a patient situation including environmental factors such as chart information and time pressures as well as individual factors such as the knowledge and skills needed by the nurse.
Faculty can develop or adapt clinical scenarios from published case study resources or obtain them from the students' clinical experience. Scenarios from real experiences tend to require minimal preparation time. Scenarios from the student's clinical day are excellent to use in a clinical postconference, but the disadvantage of real cases is that they come with predetermined outcomes. Educator-developed cases, or clinical scenarios, may unfold over time, and outcomes can be dependent on student actions.26-28 Such scenarios should include enough information for students to practice all steps of the CJM, but creating these scenarios will arguably take more time than using prompts to work through a real-life cases.
Clinical scenarios when used as a discourse method in a classroom or clinical conference rather than using them as a graded assignment offer the advantage of providing the students the opportunity to learn from immediate feedback and instructor role modeling.19,22 Class discussion is also less time consuming for instructors because rubrics and grading are not required.
Faculty can develop a set of clinical scenarios, to use within a course or across the curriculum. The best scenarios will include multiple pieces of information. Faculty can begin with a clinical situation that includes an overview; the setting of the encounter; the client's medical diagnosis, if known; subjective and objective data (cues); relevant and irrelevant data; and any other important factors to consider such as the complexity of the environment, resources available, and the knowledge and experience level of the student.
When designing or adapting a scenario, faculty should also consider including at least 2 information sources when describing the situation such as a medical record, an SBAR (Situation, Background, Assessment, Recommendation) report, a focused examination, results of a screening tool, a picture of a significant finding, or an audio interview. It is also important to consider including factors such as the setting of the encounter, available resources or team members, or competing demands that are present. The instructor should not give students all the information at the beginning, but instead can provide additional information on student request. Educators can add new information at any point in the scenario to add complexity. The NCBSN has published a template to help write clinical scenarios, which can be used later for writing test items,5 but faculty can use other sources such as clinical cases and text resources. Several cases are available as teaching strategies from the Quality and Safety Education for Nurses website.23 The National League for Nursing Advancing Care Excellence unfolding cases are particularly helpful to use for teaching clinical judgment because they include multiple pieces of data, and they can be edited to meet the desired learning objectives and design requirements for a clinical scenario.26
Using Prompts to Work the Steps of the NCSBN-CJM
The essential element of the NCSBN's definition of clinical judgment is “the observed outcome of critical thinking and decision making,”5 and the goal of teaching clinical judgment is to make the student's thinking processes visible. There are several strategies such as talk-aloud, visual thinking strategies (VTSs), questioning, or using prompts that faculty can use to elicit thinking behavior.14,29,30 The NCSBN uses prompts that faculty can use as a starting point for helping students work through each step of the CJM.31 Prompts are planned teaching questions (as opposed to questions that are used to judge students' knowledge), which when integrated into each step of the CJM make the students' thinking and decision-making processes visible.30 Prompts can be made verbally by the instructor or a student working in dyads or teams. Alternatively, the prompts can be inserted into a scenario in which students are responding to in writing. When using verbal prompts, faculty should allow students enough time to respond and offer appropriate teaching feedback. Additional prompts may be used depending on the students' responses at each step of the model.
Faculty can consider creating a template or worksheet with possible prompts for each step of the CJM as shown in the Table. When used in the classroom, students can work individually with the faculty leading the discussion of the scenario with appropriate prompts or in a role play between 2 or more students. The scenario and prompts can also be used as a written assignment. Prompts can also be added to a simulation during the debriefing or used in clinical practice as a dialogue between the student and faculty or during a post conference.
The first question might be: What cues did you recognize? The next probes should address what is most important to follow up on and if there is any information that was irrelevant. If the case is written, ask students to highlight what they think is most important. This will also begin to prepare students for possible future NCLEX highlighting items.20
The instructor can then move to guiding students to analyze the cues by asking: Which findings are normal? Which findings are abnormal? Or what findings fit together? In this step, the instructor helps the students see patterns such as fever, decreased blood pressure, and decreased platelets all fit together in a worrisome pattern in a client with a diagnosis of an infectious disease. The discussion should include what findings align with the patient's diagnosis, if known; what findings are relevant, irrelevant, or contradictory; and if there is any other information needed at this point.
Following analysis, students should generate hypotheses and then prioritize a hypothesis by determining what is most likely occurring and why. The prompts used in VTSs can be helpful: What is going on? And what makes you say that?29 A major consideration in hypothesis generation is identifying the worst outcome that might happen if the problem is not treated. The third VTS prompt “Can you find more?” may be used to help students think more deeply at any point of the case.29
Next, the student should generate solutions and create a plan of care, which includes goals or outcomes. Faculty can prompt the students by asking: “What are the desired outcomes related to your hypothesis?” and should ask students to provide at least 2 outcomes. Faculty might then ask: “What interventions are indicated, and which should be avoided?” Students should be able to identify the multiple interventions that are needed to achieve the desired results. It is also important for students to identify any actions that are contraindicated. Because the process is iterative, it may be necessary to conduct additional assessments and gather more information.
To teach students to take action, instructors may direct students to focus on the specific ways in which they would implement the plan of care. The instructor can ask the student: “What intervention(s) are needed immediately?” Another question might be: “What interventions can you delegate and to whom?” The instructor might have students create a timeline for implementing interventions, list what tasks can be delegated, write a teaching plan, or prepare a report for a referral. If medications are involved, students should be able to articulate nursing considerations including specifically how drugs should be administered, the major adverse effects, and if there are special precautions for the patient.
The final step is to evaluate outcomes to determine the effectiveness of the interventions. In a classroom setting, instructors can provide data for students to evaluate outcomes. If data are not available, teaching should focus on what data students should plan to collect, at what time frame, and what the desired findings would be. The discussion should include any critical values that would require immediate attention. Other prompts could include: “What follow-up data are needed?” “What findings would show an intervention is working and is not effective?” “Are there any critical values to monitor?” At any point in the process, the instructor should consider asking students if they still think their original hypothesis is the primary problem. If not, the educator can repeat the process.
Patient safety concerns resulting from the lack of appropriate clinical judgment in new nurses along with the planned changes to NCLEX-RN combine to make the need for faculty in prelicensure programs to prioritize teaching students how to think over delivering content urgent. The NCSBN-CJM is an integrated model faculty can use that provides a concrete structure for teaching students to think through clinical situations and develop sound clinical judgment. Committing to integrating a CJM throughout the curriculum, using realistic clinical cases and scenarios, and having students work through all of the steps of a selected model are important ways educators can help students prepare for safe clinical practice.
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