What is included in the nurses ability to make a clinical judgment decision Select all that apply?

The NCSBN Clinical Judgment Measurement Model (NCJMM) was developed by NCSBN researchers as a framework for the valid measurement of clinical judgment and decision making within the context of a standardized, high-stakes examination. While clinical judgment and decision-making have been important elements in most prelicensure education programs for many years, significant research and development were required to isolate and measure these traits with psychometric rigor. 

To create the NCJMM, NCSBN researchers drew upon the prevailing literature in nursing, nurse pedagogy, cognitive psychology, psychological assessment, and decision science related to decision making and nursing clinical judgment. In addition, multiple investigations were conducted involving over 100 nursing experts and analysis of data from more than 200,000 NCLEX candidates. The result of this work was an evidence-based framework for developing, classifying, and scoring test items that was not only technologically attainable, but feasible within the current computerized adaptive testing paradigm of the NCLEX.

The diagram below illustrates the "layers" of the NCJMM starting from the broadest layer 0 defining the context of the clinical situation to the most specific contextual layer 4. Layer 3 outlines the cognitive aspects of clinical decision making that are directly measurable and are the basis for the development of Next Generation NCLEX test items and case studies for the NCLEX exam. Layer 4 provides examples of contextual elements that were identified in the Nursing Clinical Decision-Making: A Literature Review. More detailed information about the NCJMM and the item development process can be found in various research publications including the Journal of Applied Testing Technology, 2019 Special Issue on Assessment in Medical Education.

Underlying the NCJMM is a nursing process. However, there are varied models across educational and clinical settings, and the NCJMM was not constructed to replace any of these. No matter what model is used to teach or learn the nursing process, or whatever pedagogical framework is used to contextualize this learning, good instruction and guidance using any nursing process model will provide a solid foundation for the Next Generation NCLEX exam measuring clinical judgement. The NCJMM provides NCSBN (and potentially other users), for the first time, a method for measuring and deriving valid inferences around the nursing clinical judgment and decision-making ability of prospective entry-level nurses.

While the NCJMM neither defines nor redefines clinical judgment, it allows NCSBN (and potentially other users) for the first time a method for measuring and deriving valid inferences around the nursing clinical judgment and decision-making ability of prospective entry-level nurses.

As nurse faculty, we are tasked to educate nurse generalists. The new graduate should possess the requisite knowledge to pass the NCLEX and the requisite skills to begin practicing as a registered nurse. Imparting clinical judgment leading to clinical decision making and best patient advocacy skills is perhaps the most daunting yet most vital of these tasks.

What is clinical judgment?

To effectively and adequately impart clinical judgment, it is essential to have a working definition. Clinical judgment is the accumulation of knowledge and skills over time, which contributes to the nurse’s ability to analyze and synthesize the patient presentation, objective and subjective data, and then provide evidence-based nursing interventions to improve patient outcomes; clinical decision making. Clinical judgment also contributes to the nurse’s ability to respond to changes in patient presentations with sound clinical decision-making and patient advocacy.

It is important to remember that clinical judgment leading to sound clinical decision-making is a process. As faculty, we can foster student commitment to this process by establishing a baseline level of confidence in their ability to practice by placing them in safe simulation or clinical environments and empowering them to engage in lifelong learning.

Best practices for nursing faculty to foster clinical judgment

These are several best practices we as faculty can provide to foster clinical judgment in our nursing students.

Provide safe opportunities that challenge critical analysis skills while making sure they know they are supported. Patient presentations, objective and subjective data can present fast and furious in the clinical setting. The use of case studies in the didactic setting and engaging simulation or skills lab beyond repetitive repeat demonstrations are two ways to integrate critical analysis into the curriculum. Frequent and repeated opportunities to make mistakes in the non-hospital setting can contribute significantly to student confidence as they see themselves successfully navigating complex scenarios.

Provide reflective debriefing opportunities. Allowing students a safe environment to discuss what went right and, more importantly, what went wrong can contribute significantly to student confidence which feeds into clinical judgment and decision-making. Be sure to allow the students time to respond to each other; to problem solve as nurse colleagues before interjecting as faculty.

Do not hesitate to take students out of their comfort zone. Challenge them in their clinical assignments. It is crucial to identify the students who consistently wish to watch or choose what they perceive as the “safe patient.”

Emphasize preparation. Be sure that students receive an orientation to a unit and, if possible, provide a pre-clinical introduction to their preceptor or other nurses who will be working during the clinical rotation. This can be done during a brief meet and greet. Establish a day and time before the official clinical assignment when students can gather in a break or conference room and invite the nurses an opportunity to meet the students over treats and coffee/juices, etc. After spending time with students on the floor, utilizing a scavenger hunt to locate essential items and areas. All this goes a long way to alleviate environmental fears of the unknown.

Pre-clinical assessment of student preparedness is essential as students invariably want to “hit the floor” often not knowing what they do not yet know or are prepared for. Students should be able to articulate patient diagnosis, anticipated presentation, prioritization of data collection and interventions. A valuable pre-clinical conference strategy can include “what if” scenarios. Challenge students with brief patient scenarios for which they will have to provide a clinical-decision.

Be a visible presence in the clinical setting. Students need to know they are supported and that you are available to them when they need you.

Do not underestimate the value of the post-clinical conference. This should be the safest of places where students can discuss what went well and what did not go so well. Work to create an environment that allows students to vent frustrations, identify strengths as well as weaknesses. Encourage students to problem solve amongst each other before you jump in to solve the problem. In this way, you are fostering their ability to learn from each other. This contributes to student confidence and, ultimately, clinical judgment and decision-making.

Finally, make the experience as fun as possible. Encourage students to find humor in their humanness - remind them that they were called to the profession and that they can become the nurse they envision themselves to be.

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