The Journal of Continuing Education in Nursing

Teaching Tips 

Teaching Nurses to Make Clinical Judgments That Ensure Patient Safety

Diane M. Billings, EdD, RN, FAAN, ANEF

Abstract

Many newly employed nurses do not have the necessary skill or experience to make sound nursing clinical judgments. Thus, their actions can pose a risk to patient safety. Professional development educators, clinical educators, and preceptors can use a clinical judgment task model when teaching nurses to make accurate clinical judgments. Strategies such as using prompts with deliberate practice facilitate learning this skill. [J Contin Educ Nurs. 2019;50(7):300–302]

Abstract

Many newly employed nurses do not have the necessary skill or experience to make sound nursing clinical judgments. Thus, their actions can pose a risk to patient safety. Professional development educators, clinical educators, and preceptors can use a clinical judgment task model when teaching nurses to make accurate clinical judgments. Strategies such as using prompts with deliberate practice facilitate learning this skill. [J Contin Educ Nurs. 2019;50(7):300–302]

Recent studies indicate that 23% of newly employed nurses do not demonstrate entry-level competency and do not make clinical judgments as effectively as more experienced nurses (Kavanagh & Szweda, 2017). Furthermore, it can take several years before nurses can make high-quality clinical judgments (Lasater, Nielson, Stock, & Ostrogorsky, 2015), thus contributing to risks to patient safety. To respond to this evidence, the National Council of State Boards of Nursing (NCSBN) developed a task model of clinical judgment that can be used to frame teaching and evaluation of this complex cognitive skill (Dickison, Haerling, & Lasater, 2019). Currently, the NCSBN is developing test item types that will evaluate prelicensure students' ability to make accurate and safe clinical judgments; these new item types will be available during the 2022–2023 testing cycle. Nursing faculty are now preparing students to improve their clinical judgment skills, and professional development educators (PDEs) must assume the responsibility to ensure that clinical educators, preceptors, newly employed nurses, and all staff also are able to make accurate clinical judgments. This article describes the NCSBN clinical judgment model and teaching strategies nurse educators can use to prepare nurses to make effective and safe clinical judgments.

Nursing Clinical Judgment and the NCSBN Clinical Judgment Model and Task Model

Nursing clinical judgment as defined by the NCSBN (Clinical Judgment Model and Task Model, 2019) is “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” (p. 2). Making judgments to ensure safe nursing practice is influenced by a multitude of factors, including the experience of the nurse, the situation of the client, and complexity of the environment; content knowledge by itself is not sufficient to make accurate clinical judgments. Using all components of a clinical judgment model adds reliability and validity to making the best nursing clinical judgment possible.

Previously, nurses have been prepared to make clinical judgments using sequential and iterative processes such as the nursing process or Tanner's (2006) model of clinical judgment in nursing, but these models do not account for the complexities of the current health care environment. The NCSBN's six-step clinical judgment model more specifically delineates the process of making clinical judgments. These steps include (a) recognize cues (identifying cues from the environment, patient observations, information from health record such as laboratory values, health history, prescriptions, and distinguishes relevant from irrelevant information); (b) analyze cues (using knowledge to interpret cues and make inferences; recognizing relationships among data points); (c) prioritize hypotheses (listing possible client problems and identifying priorities); (d) generate solutions (identifying possible solutions to the problem; selecting solutions with evidence for the best outcome); (e) take action (implementing the solution); and (f) evaluate outcomes (determining results of actions, changes in vital signs, effects of treatments and pharmacologic interventions; compare actual outcomes with expected outcomes) (Dickison, Haerling, & Lasater, 2019).

Teaching Strategies to Develop Nursing Clinical Judgment Skills

The skill of making safe clinical judgments can be taught, learned, assessed, and evaluated. The goal of teaching nurses to make safe clinical judgments is to help them make their judgment behaviors deliberate and visible. Educators who are teaching nurses to develop judgment skills can facilitate learning by prompting the learner to elicit behavior as each step of the judgment model unfolds.

One strategy to elicit these thinking behaviors is to use prompts. Prompts are teaching questions (as opposed to evaluation questions) that can be used to help learners make their ability to make judgments visible for each step of the nursing clinical judgment model (Table 1).

Prompts for Clinical Judgment Tasks

Table 1:

Prompts for Clinical Judgment Tasks

The PDE or preceptor can use prompts to elicit verbal responses, such as those that might occur when providing care for a particular patient, when a group of learners is solving a case study, or when debriefing following a simulation. Prompts also can be used with written work such as providing answers to questions embedded in written case studies, in written care plans that include the thinking used when making the judgments necessary to provide care, or in a written reflection about making a clinical judgment for an actual client.

When using prompts, the educator must inform the learner that prompts/questions are used to promote learning (not evaluation) and are a conversation between the educator and learner. When prompting learners, PDEs must allow sufficient time for the nurse to respond to the prompt, and then follow up with feedback, share expertise, and allow for ambiguity of various ways of approaching the client situation. Clarifying misunderstandings and errors in judgment at each step of the judgment model is essential to ensuring judgments that contribute to patient safety. Teaching strategies that portray clinical care over time and offer the opportunity to use the full clinical judgment model—such as unfolding case studies, clinical case studies, and simulations—are effective strategies in which to embed prompts for the full use of the model.

Conclusion

If patient safety is being compromised by nurses' lack of ability to make clinical judgments, PDEs, preceptors, and faculty can benefit from using a nursing clinical judgment model that focuses attention on the learners' development of clinical judgment skills. Using prompts is one strategy for making the learner's thinking and behaviors visible, and the deliberate practice of using a full task model is one way to ensure that all nurses improve their ability to make effective clinical judgments and decrease risks to patient safety.

References

  • Clinical Judgment Model and Task Model. (2019). Next generation NCLEX news. Retrieved from https://www.ncsbn.org/NGN_Spring19_Eng_04_Final.pdf
  • Dickison, P., Haerling, K.A. & Lasater, K. (2019). Integrating the NCSBN clinical judgment model into nursing education frameworks. Journal of Nursing Education, 58, 72–78. doi:10.3928/01484834-20190122-03 [CrossRef]
  • 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. doi:10.1097/01.NEP.0000000000000112 [CrossRef]
  • 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. doi:10.3928/00220124-20151112-09 [CrossRef]
  • Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45, 204–211.

Prompts for Clinical Judgment Tasks

Clinical Judgment TaskPrompts
Recognize cues:

Observe/assess patient.

Obtain information from the chart.

Understand patient's perspective and wishes.

Distinguish relevant from irrelevant data.

What did you notice?

Which cues were relevant? Irrelevant?

What is occurring in the environment?

Which laboratory data are significant?

What is significant in the patient's history?

Analyze cues:

Recognize patterns.

Link cues.

Determine what is concerning.

Determine if additional information is needed.

How do the data link to other information?

What else do you need to know to generate a hypothesis?

What patterns do you recognize?

Prioritize hypotheses:

Cluster information.

Narrow possibilities.

Determine order of priorities.

Determine risk for action or inaction.

Provide evidence for hypothesis.

What conclusions can you make?

What other conclusions could be possible?

Which cues indicate a risk for a health problem?

Which cues indicate action is required?

What is the most important problem to manage now?

Generate solutions:

Determine desired outcomes.

Determine the best solution based on evidence.

Determine what resources are needed (e.g., people, equipment, medications).

What are possible interventions for this situation?

What solution will be most helpful for this client?

What evidence did you use to choose this solution?

What are the risks for choosing or not choosing this solution?

Take action:

Implement plan.

Perform skill/procedure.

Administer medication.

Collaborate with the team.

Teach patients/families/staff/team.

Demonstrate ethical/legal behavior.

What (e.g., people, equipment, medications) is needed to take this action?

Are there contraindications to this action?

What will you do if patient refuses the medication or treatment?

What will you do if the nurse contaminates the field?

What will you do if there are not sufficient resources or team members?

Evaluate outcomes:

Compare observed outcomes to desired outcomes.

Determine effectiveness of action (e.g., procedures, medications, teaching).

What indicates your action was/was not effective?

What action is needed next?

What (e.g., medications, laboratories, or treatments) do you need to continue monitoring?

Authors

Dr. Billings is Chancellor's Professor Emeritus, Indiana University School of Nursing, Indianapolis, Indiana.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Diane M. Billings, EdD, RN, FAAN, ANEF; e-mail: dbilllin@iupui.edu.

10.3928/00220124-20190612-04

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