The key learnings and development indicators are developmental markers indicating progress in relation to NCJ parameters. Figure 1 illustrates these parameters and how they are related. The parameters are inherent to the reasoning process associated with the perception of the clinical situation, the type of relationship with the patient and the patient’s family, the perception of the nursing role, and reflection. The reasoning process is structured around three broad activities: data collection, data analysis, and identification of interventions. Students’ perceptions of the nursing role become more complex over the three stages of development and influence the reasoning processes, as well as the other NCJ parameters. The types of relationships that students establish with patients and families also evolve, as do their perceptions of the nursing role and their reflection on their NCJ. In addition, all of the NCJ parameters influence each other (Figure 1).
The progression of learnings related to NCJ entails certain changes in these parameters that form an integral part of undergraduate nursing students’ NCJ development.
The Reasoning Process Associated With the Perception of the Clinical Situation
In the first level of NCJ development, the reasoning process is conducted in a procedural manner, one step after the other. Students view the clinical situation as a current health problem affecting the patient. In most situations, this problem is associated with a pathology—hence, the data collection oriented toward the physiopathological dimension. This is what the first student, Mary (Table 3), did with her patient, Mrs. Smith (Note. All names are pseudonyms). From this starting point, it is primarily objective data that are collected, rather than subjective data. Lasater (2007) pointed out that nursing students who are at the first level of performance (i.e., who are just beginning their education program) confine themselves only to objective data. Along the same lines, Levett-Jones et al. (2010) observed that novice nurses focus only on symptoms presented by the patient without paying attention to the context of the clinical situation.
The analysis is conducted after data collection and consists of sorting through the data to identify the patient’s needs. Not much attention is given in the analysis to the context of the situation, as the data collected have mainly to do with physiological symptoms. In sorting the data and identifying needs, students rely on declarative knowledge because, thus far, they have integrated few resources (e.g., knowledge, procedures, attitudes). Lasater (2007) and Ashley and Stamp (2014) also noted that beginning students require outside support to understand the significance of the data.
After analyzing the data and identifying patient needs, students select interventions based on the suggestions they find in scientific references—especially books—as in the example of Mary, the first-year nursing student. The selected interventions address one or more needs related to a pathology affecting the patient, but they are not prioritized. According to Benner, Sutphen, Leonard, and Day (2010), nursing students beginning their education program put all tasks, demands, and concerns requiring action on an equal footing.
In the second level of NCJ development, students realize that a clinical situation involves other equally important dimensions besides the physiopathological one, such as the psychological, sociological, and ethical dimensions. Students then move from investigating not simply a health problem but rather a health situation. It is crucial for the data collection to become more comprehensive and targeted, because applying their NCJ to partial data can result in errors (Levett-Jones et al., 2010; Thompson et al., 2013). The data regarding different dimensions of the clinical situation include both objective and subjective data, such that the students can now take into account the specific situation of the patient and family. In addition, the data collection becomes targeted, aimed at finding the most important and relevant data on these different dimensions. The interaction created between analysis and data collection is helpful in identifying what data have the greatest priority and relevance. The solicitation of subjective data from patients and their families, as described in the “accomplished” level of Lasater’s rubric (2007), is similar to the act of taking into account the specifics of the patient–family situation in the second level of the NCJ development model.
Considered as one of the three steps of the clinical reasoning process in the first level, analysis becomes the core focus of the reasoning process in the second level. Analysis is conducted in interaction with data collection, with feedback loops between the two activities. The example of Anna (Table 3) refers to these interactions between data collection and analysis when she asks questions of Mrs. Smith and her daughter to complete her assessment. Some contextual elements, such as taking into account the different dimensions of the health situation, the specifics of the patient–family circumstances, and the patient’s prior health experiences, influence the analysis and make it more contextualized than as in level one. The analysis is also further enriched by evidence and the student’s knowledge. The aim of the analysis is to identify one or more aspects of the health situation that should be given priority. For students in the second level of NCJ development, using nursing research to enhance analysis is a first step toward evidence-based practice. Levett-Jones et al. (2010) pointed out that there are several elements to be considered in any clinical situation and that this calls for skills in synthesizing and an ability to apply different kinds of knowledge, including an understanding of what constitutes evidence-based practice. Integrating evidence into nursing practice involves, for nurses as much as for students, thinking critically about the validity and reliability of studies to select the most relevant studies (Alfaro-Lefevre, 2013).
Interventions at the second level are the product of interaction between data collection and analysis of several aspects of the health situation, with priority given to one or two. First, the student must perform an assessment and discern the nature of the situation (Benner, Sutphen, Leonard, & Day, 2010), so that the interventions selected will address the most important physiopathological, psychological, social, or ethical needs identified and will be well suited to the patient and family. Anna, the second-year student, identified the psychological aspect as being the most important in Mrs. Smith’s situation and organized her interventions accordingly. The impacts of these interventions on the patient and family must also be considered. However, as noted by Lasater (2007), students at this level confine themselves to the planned interventions.
In the third level of NCJ development, the reasoning process is considered to be dynamic, as the three activities—data collection, analysis, and interventions—are continually influencing each other. The perception of the clinical situation as being a health situation, with different aspects requiring investigation, evolves, in level three, toward a more integrated view of the clinical situation, or “the big picture,” as it is called by Benner et al. (2010, p. 49). The clinical situation is no longer broken down into different components but is viewed comprehensively as a health experience that the patient and family are undergoing. To arrive at a global view of the health experience, the interaction between analysis and data collection leads to the formulation of hypotheses about the experience. These hypotheses are verified with the people concerned (i.e., the patient and his or her family) but also with the help of other data sources to supplement the data collection. The data collection process is continuous, fueled by the implementation of interventions and by their outcomes.
In the third level of development, the analysis is contextualized by accounting for the views of patients and their families, as well as their living environments. The analysis also becomes more complex because of (a) the many possible links among the data collected in the effort to take into account all of the data collected; (b) the need to adapt to new and important information; and (c) the use of a variety of resources to enhance the analysis. Adding to this complexity is the fact that the analysis interacts with the data collection and the interventions. The analysis leads to a prioritization of needs, in collaboration with the patient and family. In the vignette, Kim (Table 3), who is near the end of her undergraduate nursing program, explores with Mrs. Smith and her family their views about the patient’s return to home, and together they reach a decision. In level three of NCJ development, analysis also includes identifying needs with respect to follow-up, as well as prevention and health promotion. This description of analysis as it relates to the third level of NCJ development is part of the final profile for this competency upon completion of the bachelor’s program in nursing. It is similar to one of the main goals of nursing education program identified by Benner et al. (2010). Those authors stressed the need for students to learn to contextualize their assessment of a clinical situation by taking into account the patient’s experience, cultural references, environment, previous experiences of care, and family relationships. Contextualizing the assessment of the clinical situation requires a global view of the situation that can be used to set care priorities (Benner et al., 2010). A certain degree of flexibility is observed in interventions at the third level of NCJ development. Interventions are personalized based on the prioritized needs identified with the patient and family, while also accounting for the time available and the care environment. Other professional resources could also be requested to address these needs. In interaction with data collection and analysis, interventions are also adjusted as new, and important data are gleaned. It is essential that the student keep abreast of any changes occurring in a clinical situation, as these modify action priorities (Benner et al., 2010).
In summary, the manner in which the reasoning process is conducted in the first level of NCJ development resembles an analytical process and, more specifically, a hypothetico-deductive process. This type of process is predominant among students (Lasater, 2007) and novice nurses (Tanner, 2006; Thompson et al., 2013). Although more dynamic than in level one, because of the interaction between data collection and analysis, the reasoning process in the second developmental level nevertheless remains essentially analytical. However, in the third level of NCJ development, the consideration of the views of the patient and family on their health experience is more akin to a narrative reasoning process (Tanner, 2006). Nursing students who reach the third level are still using an analytical process, but in combination with a narrative process.
The Nature of the Relationship With the Patient and Family
Over the course of the three levels of NCJ development, the nature of the relationship between the nursing student and the patient and family is transformed. In the first level, the relationship is centered on the patient and involves communication aimed at eliciting information from the patient about the health problem. The focus is on active listening in a relationship that is more social than professional. From this standpoint, according to Levett-Jones et al. (2010), the patient is seen primarily as a data source. In the second level, a professional relationship is created. In contrast to level one, the relationship now also includes the patient’s family. The student considers the patient and family as a unit in themselves, with a specific character. When exercising NCJ, the student takes this specific character into account. The student engages in a professional relationship with the patient and family by taking on the nursing role. In level three of NCJ development, the student actively solicits the views of the patient and family on their health experience, and this information then influences the student’s NCJ. The student fosters a collaborative relationship by involving the patient and family in identifying needs and setting priorities and personalizes the care to meet those needs. It is this understanding of the patient’s perceptions that makes it possible to personalize the interventions (Tanner, 2006).
Underlying the transition from a social relationship in the first level of development to one of collaboration with the patient and family in level three is a progressive recognition of the patient as a person. This person has a family, and together they have their own perceptions of the health experience they are undergoing. The patient is no longer the object of care and instead becomes a human being in the eyes of the student, who, to help the patient, needs to understand the patient’s concerns (Benner et al., 2010). Levett-Jones et al. (2010) emphasized the influence that this recognition of the person’s uniqueness has on decision making. According to Tanner (2006), knowledge of the patient and his or her reactions is one of the defining features of solid clinical judgment.
The Perception of the Nursing Role
While developing NCJ over the course of their program, students gradually take on the nursing role. They develop a conception of the nursing discipline that influences the way they embody this role. In the first level of NCJ development, students enter into their professional role in care provision. They become particularly conscious of the professional responsibilities inherent in this role, including that of ensuring patient safety. This consideration for patient safety primarily takes the form of asking for assistance as needed and seeking advice from a resource person on the safety of a planned intervention. Levett-Jones et al. (2010) agreed with this view of the safety of care provided by nursing students. They explained that students require communication skills and a certain amount of self-confidence to let the care team know when they need help. In this first stage of NCJ development, the student role takes precedence over the nursing role.
In the second level of development, students experiment with the nursing role. This experimentation occurs in their interactions with patients and families, as well as with health professionals, with whom they discuss clinical situations. In these professional interactions, students detach themselves from their role as students and take on the role of nurse, which they are exploring. This concrete exploration of different aspects of the nursing role enables students to integrate a comprehensive vision of that role. This integration of a comprehensive vision of the nursing role is expressed in the third level of NCJ development. It influences students’ interactions with patients and families, their perception and consideration of different aspects of clinical situations, and their identification and prioritization of needs, including needs related to follow-up, prevention, and health promotion.
The accumulation of key learnings about the nursing role over the course of the three NCJ development levels provides the foundation for the progressive construction of professional identity. Along these lines, Benner et al. (2010) noted that students act like nurses as they begin their education program and gradually become nurses over time. This nursing role influence was incorporated into the guide developed by Nielsen, Stragnell, and Jester (2007) to help students reflect on their NCJ.
Between the first level of development and the third, students’ reflection on their own NCJ evolves. In level one, their metacognitive strategies are centered on the learning itself. At the start of the education program, students find it difficult to evaluate their performance with regard to their NCJ (Ashley & Stamp, 2014; Lasater, 2007). However, students engage in a process of continuous learning of NCJ by demonstrating a self-critical approach to evaluating their own performance and a willingness to receive feedback and by taking steps to optimize their learning. In the second level, students’ metacognition is focused on their NCJ. They begin a reflexive practice on NCJ as they demonstrate autonomy and self-confidence about their capacity for reflection. They reflect on their own reasoning process and on the care provided, with a view to self-regulation. In this way, nursing students learn from their experience, acquire more knowledge, and improve their clinical judgment and reasoning (Tanner, 2006). In level three, students push their reflection even further and are able to discuss their NCJ with various health professionals, which involves being able to explain and defend it. Thus, students’ metacognitive strategies are broadened from one level to the next, reinforcing their reflexive practice on their NCJ. Several nursing researchers (Alfaro-Lefevre, 2013; Fonteyn & Ritter, 2008; Lasater, 2007; Levett-Jones et al., 2010; Nielsen et al., 2007; Tanner, 2006) have highlighted the importance of reflection in strengthening NCJ. The progressive expansion of reflexive practice over the course of the three levels of NCJ development influences the development of students’ reasoning processes, their appropriation of the nursing role, and the transformation of their relationships with patients and families.
In fact, all of the parameters of NCJ influence each other and advance together in terms of learning. These advances in learning support the emergence of students’ autonomy in deploying this competency. The presence of mutual influences among the NCJ development parameters supports the necessity of acquiring all the key learnings associated with a development level to complete that level. Figure 2 summarizes the three stages of NCJ development in undergraduate nurse education.
Development of nursing clinical judgment (NCJ) in undergraduate nursing education. Reflexion = reflection.