What clinical judgment and decision making takes place as the nurse responds to these changes

<2-min.> NCSBN's foremost expert on the Next Generation NCLEX discusses some subtle distinctions in verbiage regarding a new test to assess clinical judgment.

The following is a transcript of the above video conversation between Philip Dickison, PhD, RN, Chief Officer, Examinations, NCSBN, and Sheryl Sommer, PhD, RN, CNE, Vice President, Chief Nursing Officer, ATI.*
Several years, the National Council of State Boards of Nursing (NCSBN) began researching the topic of clinical judgment in the nursing profession. Its efforts identified the need to assess clinical judgment in nursing graduates using the organization's lauded licensure examination, the NCLEX.

But what is clinical judgment? We asked Dr. Dickison to explain.

Q: What’s the difference between clinical judgment and similar phrases, such as clinical reasoning, decision-making, or clinical decision-making?

A: These are words, but they need to be defined, okay? And so what we did was that there's this sort of combination of some new information in the cognitive science.

So, you have a lot of research on critical thinking and you have this new — well, not brand new, but new compared to other lines of cognitive — and it's called decision theory, right? And so we said, let's take a look at the combination of critical thinking and decision theory. And it is out of that that comes this thing called clinical judgment. I would argue that's probably just a name that is clinical reasoning. If someone is saying clinical reasoning, I generally stop and say, "What do you mean by that?" so I'm sure that we're all talking about the same thing, right? Or somebody says, "Clinicals are critical thinking." What do you mean by that? Because I need to know that we're talking about the same thing.  Generally, in my world, I would say — and I know that some others won't — but that we're talking about clinical judgment. It may be an umbrella of critical reasoning. I suggest that they're probably just saying it because reasoning requires you to go through the same steps as judgment. 

Clinical judgment = the final decision

Clinical reasoning = the process

Judgment suggests that that's the final decision; reasoning is the process. Maybe, at the end of this, we call it clinical reasoning. I don't know. We have chosen clinical judgment and have established an operational definition for it, so we all know that's what we're talking about.

NCSBN’s Operational Definition of Nursing Clinical Judgment:

An iterative decision-making process that uses nursing knowledge to:

• Observe and assess presenting situations
• Identify a prioritized client concern
• Generate the best possible evidence-based solutions in order to deliver safe client care.

*This discussion took place at that National Nurse Educator Summit in April 2018 in Salt Lake City.

DO YOU HAVE QUESTIONS ABOUT DEFINING CLINICAL JUDGMENT? ASK THEM IN THE COMMENTS BELOW.

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Volume 21, December 2016, Pages 280-293

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Clinical nursing environment

Cognitive reasoning skills

The nursing process has been used for over 50 years as the systematic, stepwise method for problem solving to make safe, client-centered clinical decisions. Originally, there were four nursing process steps, published in the late 1960s. These were:

• Assessment
• Planning
• Implementation
• Evaluation

In the early 1970s, the North American Nursing Diagnosis Association (NANDA, currently called NANDA-I) was formed to develop a common language to identify standardized nursing diagnoses based on a nurse’s interpretation of assessment data. As a nurse educator, you likely include this additional step of Diagnosis as part of the nursing process, referred to as ADPIE:

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

Using a problem-solving approach as a basis for nursing practice requires the use of critical thinking and decision-making. Some experts have referred to that thinking more recently as clinical reasoning. The 2020 NCLEX-RN® Test Plan identifies the nursing process as one of five integrated processes which is defined as “a scientific, clinical reasoning approach to client care that includes assessment, analysis, planning, implementation, and evaluation” (NCSBN, 2019, p.5). Note that this definition does not include Diagnosis; rather the second step of the nursing process is labeled as Analysis.

The NCLEX-RN® and NCLEX-PN® do not measure the nursing graduate’s knowledge of nursing diagnoses (NDs) because NDs are not universally used as originally intended as a standardized language, even in the United States where the NANDA nursing diagnosis list began. Yet many faculty continue to teach the nursing process as a five-step ADPIE approach.

Comparing the Nursing Process and Clinical Judgment

While the nursing process has been taught in prelicensure programs for many years, nurses continue to make serious errors in practice, including failure-to-rescue clinical situations that sometimes result in sentinel events. Based on these errors and employer dissatisfaction with the clinical-decision ability of new graduates, the National Council of State Boards of Nursing (NCSBN) developed a model of clinical judgment that is built on and expands the nursing process. Officially entitled the NCSBN Clinical Judgment Measurement Model (NCJMM), this evidence-based model identifies six cognitive skills needed to make appropriate clinical judgments. These skills include:

• Recognize Cues
• Analyze Cues
• Prioritize Hypotheses
• Generate Solutions
• Take Action
• Evaluate Outcomes

The NCJMM will be the basis for the Next-Generation NCLEX-RN and NCLEX-PN (NGN) new test items that will be presented most often in an unfolding case format. These cases will present clinical situations in which the test candidate will need to use clinical judgment skills to answer questions about how to manage the presented client’s care.

If you are teaching in a state, province, or territory in which the nursing process is required as a regulation for prelicensure nursing education, follow these guidelines to help transition from the nursing process to clinical judgment:

• Use the term clinical judgment as part of your program’s definition of professional nursing and end-of-program student learning outcomes (also called program learning outcomes).
• Introduce the nursing process in your first basic nursing course as the foundation for clinical decision-making.
• Minimize emphasis on the NANDA nursing diagnosis list and ensure that students understand that the diagnostic labels and taxonomy are not universally used in health care today. Instead, assist students in learning the signs, symptoms, and behaviors that nurses and other interprofessional health care team members utilize and understand. For example, fever is a more commonly used term in nursing and health care than hyperthermia. A nurse can take a client’s body temperature and determine that he or she has a fever if the thermometer reads 103oF (39.4oC).     
• Introduce the NCSBN definition of clinical judgment and the six cognitive skills of the NCJMM early in your nursing program.
• Have students practice using the six cognitive skills in a variety of learning activities, including unfolding case studies in place of excessive lecture throughout your program.

Building on the Nursing Process to Transition to Clinical Judgment

As you and your students transition from the nursing process to clinical judgment, remember that clinical judgment is more closely aligned with how nurses in practice actually think to make the best possible decisions about client care. Also recall that clinical judgment in nursing is not a new concept. For example, Tanner, the National League for Nursing, and others have posited for almost 15 years that clinical judgment is a better problem-solving approach than the nursing process.

The NCJMM cognitive skills can be aligned with the nursing process steps and phases of Tanner’s clinical judgment model as illustrated below:

Comparison of the Nursing Process with Tanner’s Clinical Judgment Model and the NCSBN Clinical Judgment Measurement Model (NCJMM)

While these models may look very similar, the thinking processes differ. For example, in the Assessment step of the nursing process, the nurse collects subjective and objective client data using a systematic approach. By contrast, the Recognize Cues cognitive skill of clinical judgement requires the nurse to collect client data and then decide “What matters most?”—which client data (findings) are relevant in a specific contextual clinical situation and which data are not relevant? Two other examples comparing the nursing process steps and the cognitive skills of the NCJMM are described below:

As you begin or continue making the transition of building on the nursing process to emphasize clinical judgment in your program, remember that clinical judgment will be the focus of the new test item types for the NGN by no sooner than 2023. You still have time to begin the transition journey, but we suggest that you start it soon! More NGN resources are available on www.ncsbn.org and the Elsevier Evolve Faculty Resources webpage.

Reference:

National Council of State Boards of Nursing (NCSBN). (2018). NCLEX-RN® Examination: Test plan for the National Council Licensure Examination for Registered Nurses. Chicago, IL: Author.