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Clinical Judgment Insights

UNDERSTANDING THE CRUCIAL IMPACT OF DEVELOPING CLINICAL JUDGMENT SKILLS

No aspect of nursing today is more important than developing the skill of clinical judgment. NCSBN has zeroed in on this skill as the reason for creating a new version of the NCLEX (commonly referred to as Next Generation NCLEX).


Scroll down to find resources for developing your students' clinical judgment skills.


CLINICAL JUDGMENT & THE IMPACT ON PUBLIC SAFETY

NEW NURSES RELY ON CLINICAL JUDGMENT FOR NEARLY EVERY TASK.

The NCSBN's observational practice analysis showed that the linking factor in almost any task that an entry-level nurse performed was the ability to make judgments on the spot based on the evidence presented.

A decade of performance-based development system assessments representing more than 10,000 new graduate RNs reveals an alarming year-over-year decline in initial competency.“ (Kavanagh, Sharpnack, 2021)

Phil Dickison, PhD, RN, the NCSBN's Chief Officer, Operations & Examinations, explained, “Many of these judgments … have the biggest impact in urgent or emergent situations.” 

What was especially concerning to the NCSBN was the data that new nurses were regularly making errors, and 60% of them were directly related to clinical judgment. About half of the errors led to remediation or disciplinary action. This knowledge is important because clinical errors quite often affect client safety and lead to client harm.

It was clear to the NCSBN that assessing clinical judgment in nursing candidates was imperative


CLINICAL JUDGMENT: NCSBN'S OFFICIAL DEFINITION

HELP STUDENTS UNDERSTAND WHAT IT MEANS.

The NCSBN has defined clinical judgment for the nursing profession as "the observed outcome of critical thinking and decision-making."

Further, clinical judgment is 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.

 


    CLINICAL JUDGMENT: EVIDENCE-BASED ADVICE

    RESEARCH PROVIDES INSIGHTS ON HOW TO INCORPORATE CLINICAL JUDGMENT IN LESSONS.

    • In cases where students face limitations in credit hours and clinical sites, use unfolding case studies to develop clinical judgment given the established link between dynamic case studies and clinical practice experience. Simulation can also play a role in developing sound clinical judgment. Shatto et al (2017) demonstrated that at least three simulation experiences can contribute to significant clinical judgment development in nursing students. (Hussein et al, 2021)
    • Have students review encounters in an unfolding clinical scenario. Ask students to provide evidence-based responses and behaviors based on the associated clinical judgment functions. (See page 41.) This strategy allows educators to promote deep learning, foster the development of clinical judgment, and evaluate student learning. (Sommer et al. 2021)
    • Show students why tasks require problem solving, critical thinking, and clinical judgment.(NCSBN, 2018)
    • Focus on six instruments that measure clinical judgment: simulation-based experience exposures, specific nursing specialty simulations, debriefing and its effect on clinical judgment, assessment, clinical decision-making, and reflection. (Klenke-Borgmann, et al, 2020)
    • Use concept-based strategies that engage students in deliberate practice with concepts as they manifest in a variety of contexts. This technique will increase the number of experiences upon which students can draw to reason through patient situations. (Jessee, 2021)

     

    Learn more:

    Sommer, S.K., Johnson, J.D., Clark, C,M,, Mills, C.M. Assisting learners to understand and incorporate functions of clinical judgment into nursing practice. Nurse Educator. 2021;46(6):372-375. doi: 10.1097/NNE.0000000000001020

    Jessee, MA. (2021). An update on clinical judgment in nursing and implications for education, practice, and regulation. Journal of Nursing Regulation, 12(3), 50-60. DOI:https://doi.org/10.1016/S2155-8256(21)00116-2

    Dickison, P., Haerling, K.A., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing clinical judgment model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72-78. https://doi.org/10.392801484834-
    20190122-03.

    NCSBN (2018). Strategic practice analysis. NCSBN Research Brief, 7,11-15. https://www.sciencedirect.com/science/article/pii/S2155825621001162

    Manetti, W. (2018). Sound clinical judgment in nursing: A concept analysis. Nursing Forum, 54(1), 102-110. https://doi.org/10.1111/nuf.12303

    Hussein, M., Olfert, M. & Hakkola, J. (2022). Clinical judgment conceptualization scoping review protocol. Teaching and Learning in Nursing, 17, 84-101. https://doi.org/10.1016/j/teln.2021.10.003.

    Jessee, M. A. (2021). An update on clinical judgment in nursing and implications for education, practice, and regulation. Journal of Nursing Regulation. 12(3), 50-57. https://www.sciencedirect.com/science/article/pii/S2155825621001162

    Klenke-Borgmann, L., Cantrell, M. & Mariani, B. (2020).
    Nurse educators’ guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41(4), 215-221. https://doi.10/1097/01.NEP0000000000000669.

     


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    THE ATI GUIDE FOR CLINICAL JUDGMENT

    TRAINING GUIDE: ATI'S EXPERT NURSE EDUCATORS

    This paper assists you in developing and implementing learning materials to promote clinical judgment skills. Use it as a framework for creating learning activities such as simulation scenarios, writing unfolding case studies, and developing test items. Read More
    Clinical judgment: Teaching & learning
    Clinical judgment: Environmental & Individual Factors
    Clinical judgment: Expected responses

    DEVELOPING CLINICAL JUDGMENT SKILLS: STRATEGIES THAT MAKE STUDENTS THINK

    POWERPOINT: SHERYL SOMMER, PHD, RN, CNE, AND JANEAN JOHNSON, MSN, RN, CNE

    Originally planned as the backbone of a session at the 2020 National Nurse Educator Summit (before being cancelled by the pandemic), this presentation will be helpful for planning how to incorporate clinical judgment into your curriculum. Read More

    CLINICAL JUDGMENT MODEL COMPARISON THEORIES CIRCLE

    LEARNING ILLUSTRATION: SHERYL SOMMER, PHD, RN, CNE

    The similarities between the Nursing Process, Tanner's Clinical Judgment Model, and NCSBN's Clinical Judgment Measurement Model have much in common. This illustration highlights their similarities. Read More

    2 EXPERTS EXPLAIN HOW SIM HELPS BUILD CLINICAL JUDGMENT SKILLS

    INTERVIEW: BETH PHILLIPS, PHD, RN, CNE, AND SUZAN KARDONG-EDGREN, PHD, RN, ANEF, CHSE, FSSH, FAAN

    Discover advice from 2 of the foremost experts on the use of simulation in effectively helping students build critical clinical judgment skills.
    Read More

    BUILDING CLINICAL JUDGMENT: USING SIM FOR CLINICAL REPLACEMENT

    INTERVIEW: BRENDA S. WILLIAMS, DNP, MSN ED., BSN, RN, CNE, CHAMBERLAIN COLLEGE OF NURSING

    The 2018 Teaching Forward Award recipient describes how she ensured her students were getting the clinical experience they needed. Her ingenious idea? To convert ATI's Real Life Clinical Reasoning scenarios from a group project into individual projects.
    Read More

    CLINICAL JUDGMENT CONCERNS: RELATED READING

    JOURNAL ARTICLES: A COMPILATION

    The need for stronger clinical judgment skills in nursing students has researchers worldwide searching for answers. Here, we gather a selection of journal articles to provide further reading and help you identify opportunities to strengthen students’ clinical judgment skills.
    Read More

    NCSBN’S PHIL DICKISON EXPLAINS THE VITAL NEED FOR IMPROVED CLINICAL JUDGMENT

    INTERVIEW: DR. PHIL DICKISON

    At the National Nurse Educator Summit in April 2018, we probed for details on this crucial issue from the industry’s foremost expert on the topic and how it became the foundational core of the Next Generation NCLEX. Read More

    CLINICAL REASONING VS. CLINICAL JUDGMENT: WHAT’S THE DIFFERENCE FOR NEXT GENERATION NCLEX?

    INTERVIEW: DRS. PHIL DICKISON AND SHERYL SOMMER

    In a series of interviews with ATI, NCSBN's foremost expert on the Next Generation NCLEX discusses how the organization is taking an analytical look at the exam. NCSBN hopes to determine whether its test can accurately assess student nurses’ clinical judgment. Read More

    CLINICAL JUDGMENT: CRITICAL COMPONENTS & ASSESSMENT

    INTERVIEW: DRS. PHIL DICKISON AND SHERYL SOMMER

    NCSBN's foremost expert on the Next Generation NCLEX sat down with ATI to discuss the organization's initiative in creating a wholly new version of the exam. The goal: To determine whether the NCLEX can accurately assess student nurses’ clinical judgment.

    Read More


    CLINICAL JUDGMENT: USING EFFECTIVE TECHNIQUES

    ADOPT TEACHING TECHNIQUES BASED ON RESEARCH.

    Based on the research noted on the previous page, use these techniques to help students develop their clinical judgment:

    • Emphasize what is most important 
    • Use cognitive and experiential strategies — active learning —that promote higher-level thinking, such as thinking out loud and reflection
    • Make assignments that are appropriate yet realistic for the student’s level
    • Deliver one-on-one interaction and coaching 
    • Encourage interaction with other healthcare team members
    • Incorporate quality feedback that:
      • Is timely and specific
      • Identifies strengths/deficits
      • Shares alternative perspectives
      • Recommends ways to improve.

     


    PRACTICAL TEACHING TIPS

    HELP STUDENTS DEVELOP CLINICAL JUDGMENT SKILLS IN 3 PRIMARY WAYS:

    1) Use active-learning strategies.

    The use of a variety of active-learning strategies promotes the necessary deep-thinking skills required for developing clinical judgment. Incorporate case studies, video scenarios, and simulation to help students better grasp the concepts being addressed, particularly when they have not had similar experiences in clinical. 

    2) Thoroughly assess all assignments.

    Make sure any assignment you give students is relevant and challenging yet realistic for the level of your learners. Your goal should be to increase their curiosity and motivation so they thoughtfully complete the work.

    3) Question using the Socratic method.

    This back-and-forth technique is recognized for promoting deep thinking. Require students to examine collected data, compare and contrast findings, provide rationales for their responses, and explain interrelationships. 

    Read more about active-learning strategies in these research papers written by ATI's Drs. Annie Moore-Cox and Karin Roberts:

     


    ADVICE FOR USING THE SOCRATIC METHOD

    ASK INSIGHTFUL QUESTIONS TO ELICIT DEEPER THINKING ABOUT A TOPIC OR ISSUE.

    Socratic questioning is a technique that is especially useful in helping students develop their clinical judgment skills. In essence, you ask a question specifically designed to elicit discussion that clarifies information, justifies a student's response, or probes further.

    Clarification

    • “Tell me what you found during the client assessment."
    • "What is the client’s priority health problem?”

    Justification

    • “What prompted you to collect that data during your assessment?”
    • "What evidence supports this as the client’s priority problem?”

    Probing

    • “Describe implications of the assessment findings.”
    • “Explain your thinking about selecting this as the priority problem.”

    PEOPLE ALSO ASK ...

    WHAT ARE THE KEY ELEMENTS OF CLINICAL JUDGMENT?

    The NCSBN has defined clinical judgment for nurses as "the observed outcome of critical thinking and decision-making." The organization further describes clinical judgment as 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.

    WHAT IS CLINICAL JUDGMENT IN NURSING?

    Clinical judgment refers to the way nurses develop their thinking process to understand the problems, issues, or concerns of their clients. It ultimately impacts client safety.

    WHY IS CLINICAL JUDGMENT IMPORTANT IN NURSING?

    The NCSBN performed an observational practice analysis, which showed that clinical judgment is the linking factor in almost every task performed by an entry-level nurse. A nurse's clinical judgment skills impact how quickly and accurately they can make on-the-spot judgments based on the evidence presented.