Which concept is the focus of Layer 4 of the clinical judgment Measurement Model CJMM )?

Introduction to the Clinical JudgmentNursing Process and the ClinicalJudgment Measurement ModelSince as early as 1955, nursing practice has been based on the nursing process, an organized andsystematic five-step process: assessment, analysis, planning, implementation, and evaluation.More recently, the National Council of State Boards of Nursing (NCSBN) determined that 50%of nurses are involved in some type of error, with 65% of the errors occurring as a result of poorclinical decision making (NCSBN, 2018, p. 11). The NCSBN (2018) also revealed that a mere20% of employers were satisfied with the decision-making skills of new nurses (p. 11). As aresult, the NCSBN developed a new comprehensive clinical judgment model: the ClinicalJudgment Measurement Model (CJMM). The following table identifies concepts that are similarbetween the nursing process and the CJMM.Nursing ProcessClinical Judgment Measurement ModelAssessmentRecognize CuesAnalysisAnalyze Cues and Prioritize HypothesesPlanningGenerate SolutionsImplementationTake ActionEvaluationEvaluate OutcomesMeasurement ModelBackground and PurposeThe NCSBN created the CJMM to provide a strong framework to support new ways ofevaluating clinical judgment as part of the nursing licensure examination (NCSBN, 2019a). TheNCSBN further developed an action model to integrate the concepts identified in the CJMM innursing education. The CJMM directly applies to nursing practice, as it provides a sound

foundation to assist nurses in planning nursing care for all types of patients in a variety ofsettings.The NCSBN (2019b) defined clinical judgment as “the observed outcome of critical thinking anddecision making” (p. 1). Nursing clinical judgment is an essential nursing skill in the modernhealth care environment, as nurses manage a wide variety of information and select actions toprovide safe, appropriate care for patients including the following:Unique cultural, developmental, and social influencesPersonal preferences of the patientMedical history informationPathophysiologyPatient cues/dataChanges in patient statusNursing interventions, including medication administrationCommunication with health care team membersCommunication with family members and support systemDocumentationManagement of multiple patients simultaneouslyA new graduate nurse might not initially be able to make the same high-level, quality clinicaljudgments as efficiently as a more experienced nurse. However, both new and experiencednurses must demonstrate effective observational and reasoning skills to yield clinical judgmentsthat promote optimal patient healing and wellness, and prevent adverse patient events.Components of CJMMThe CJMM reflects a shift in thinking from the nursing process, even though it consists of layers(0, 1, 2, 3, and 4) representing some of the same types of concepts as the traditional nursingprocess (NCSBN, 2019b).

NGN Measurement Model (Copyright © 2019 NCSBN. All Rights Reserved.)

What is the Nursing Process?

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.

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