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Frameworks to Teach Clinical Judgment

By July 6, 2021June 2nd, 2023No Comments

Did you know that almost half of all tasks that a nurse does involves making clinical decisions? Yet fewer than ¼ of graduate nurses, all who have passed the NCLEX, are competent in clinical judgment.

Everything we do as nurses impacts patient outcomes, so it is imperative that nurses graduate ready for safe clinical practice. Developing clinical judgment in our students is the key to ensuring they are ready to care for patients when they graduate. 

What is clinical judgment?

First, it’s important to define clinical judgment. Clinical judgment is the nurse’s conclusion that recognizes then correctly interprets relevant clinical data to determine the best response.

Clinical judgment is an OUTCOME dependent on the nurse’s critical thinking and clinical reasoning skills. For a concise definition, watch this short video

The Next Generation NCLEX will Measure Clinical Judgment

The National Council of the State Boards of Nursing (NCSBN) will launch the Next Generation NCLEX (NGN) in April 2023 to better measure candidates’ clinical judgment ability, a proven necessity for entry-level nurses. 

The essence of NGN is evaluating clinical judgment using case-based scenarios and 6 questions that represent the NCSBN evaluation model of clinical judgment.

To develop clinical judgment use the following three models in this suggested sequence:

  1. The nursing process (simple-foundational)
  2. Tanner’s Clinical Judgment Model (CJM) (simple-foundational)
  3. NCSBN Clinical Judgment Action  Model (complex-advanced)

To develop clinical judgment, use the same principle that is used in the curriculum. Begin with simple and progress to complex.

The nursing process is a simple foundational framework. To develop clinical reasoning skills that lead to clinical judgment, Tanner’s CJM has only four processes and another strength is that it is practice-based.

Therefore, consider this theoretical framework of clinical judgment as simple and foundational and introduce at the same time as the nursing process.

Once the foundation has been laid and students have had repeated exposure to using both models to develop clinical judgment, then build on this foundation with the more advanced and complex model of clinical judgment the NCSBN NextGen model.

Framework #1: Using Nursing Process as a Foundation

The nursing process should be used as a foundation that a nurse uses to learn and practice thinking like a nurse. This foundational and fundamental framework is already integrated into the nursing curriculum and remains relevant to nursing practice.

Some educators have suggested that the nursing process is the reason nurses aren’t prepared for practice and after 60 years needs to be considered. I strongly disagree — the nursing process isn’t the problem. It’s how we’re teaching it.

Just as the nursing curriculum is structured from simple to complex, the first framework of nurse thinking should also be simple and fundamental.

Here are the steps:

  • Assessment
  • Analysis
  • Planning
  • Implementation 
  • Evaluation 

Framework #2: Tanner’s Clinical Judgment Model

The second framework that builds on the nursing process is Tanner’s Clinical Judgment Model.

This is a research- and practice-based framework first published in 2006 that was derived from a synthesis of over 190 nursing studies on clinical judgment by Chris Tanner. The model aligns with the nursing process to successfully develop the clinical reasoning skills students must master for practice and licensure.

Tanner’s model identifies four clinical reasoning processes (how a nurse thinks) needed for students to make the correct outcome of a clinical judgment.

  1. Noticing – What clinical data does the nurse recognize as important or significant?
  2. Interpreting – What is the meaning or clinical significance of relevant clinical data that was noticed?
  3. Responding – How will the nurse respond with a nursing priority and plan of care based on the clinical data that was noticed and interpreted?
  4. Reflecting – After responding, what is the evaluation, reflecting on the clinical data noticed by the nurse?

As educators, we can do things differently to develop these skills. For example, in the interpreting step, does clinical paperwork require students to capture trending data? Is the patient improving or worsening? This is an important noticing skill of clinical reasoning that leads to the outcome of a correct clinical judgment.

Framework #3: NCSBN Clinical Judgment Action  Model 

Tanner’s Clinical Judgment Model was used to provide the foundation of the NCSBN model of clinical judgment and aligns with each of the six steps of the NCSBN model. See how the models overlap.

Step 1: Recognize cues

Step 2: Analyze cues

Step 3: Prioritize hypotheses

Step 4: Generate solutions

Step 5: Take action

Step 6: Evaluate outcomes

In the NextGen NCLEX, students will need to complete at least three case-based scenarios complete with medical records that have six sequential questions that correlate to each of the six sequential steps of the NCSBN model.

The NCSBN model adds to Tanner’s CJM by adding an additional process of step 3: Prioritizing hypotheses, which requires the nurse to identify which problems are most/least likely by using pattern recognition which is an advanced clinical reasoning skill that requires time and experience in the clinical setting to develop.

The NCSBN model adds to Tanner’s CJM by adding an additional process of step 4: Generate solutions to Tanner’s step of Responding, which requires the nurse to identify desirable patient outcomes.

In Closing

Nursing education remains in need of radical transformation to develop the clinical judgment your students require for safe practice.

By integrating the nursing process and Tanner’s Clinical Judgment Model as the simple foundation for nurse thinking in your curriculum and then building on this with the more complex NCSBN NextGen model in the final year or semester, your students will be well prepared for both clinical practice and licensure including Next-Gen!

Learn more in this video:

Related Reading and Resources

Educator Resources

KeithRN case studies are unique and unlike any other case studies available to educators because they integrate Tanner’s Clinical Judgment Model with open-ended questions, come in different levels of complexity, and have a consistent structure. These case studies are an effective tool for practicing clinical reasoning skills that lead to clinical judgment.

The new Faculty Guide to Develop Clinical Judgment empowers educators with educational best practices and practical strategies to effectively develop clinical judgment in the class, clinical, simulation, and virtual settings!

Keith Rischer – Ph.D., RN, CCRN, CEN

As a nurse with over 35 years of experience who remained in practice as an educator, I’ve witnessed the gap between how nursing is taught and how it is practiced, and I decided to do something about it! Read more…

The Ultimate Solution to Develop Clinical Judgment Skills

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