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Frameworks to Teach Clinical Judgment

By July 6, 2021No 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.

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 framework is already integrated into the 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.

Look at the steps:

  • Assessment 
    • Diagnosis/Analysis – We focus too much on NANDA 3-part nursing diagnostic statements. It doesn’t capture the essence of how nurses think in practice. 
  • Planning 
  • Implementation 
  • Evaluation 

If we want to develop clinical judgment, use the nursing process, but emphasize analysis instead of diagnosis which infers a NANDA nursing diagnosis; most NANDA diagnostic statements do not capture the essence of how a nurse thinks in practice. Therefore, let’s question the way we teach and align priority setting with practice!

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 proven research- and evidence-based framework first published in 2006. 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.

How to Use the NCSBN Model

Many prominent nurse educators are encouraging the use of the NCSBN model used in Next Gen NCLEX to teach clinical judgment throughout the curriculum; however, the evaluative model for NCLEX is NOT a practice-based model, it is an EVALUATION model only that has no research to validate its use as a PRACTICE-based model. 

Teaching for the test (NCLEX), not to practice, only widens the gap between how nursing is taught and practiced. To develop clinical judgment, start with the nursing process to lay the foundation as a simple framework. Then build on the foundation integrating Tanner’s Clinical Judgment Model.

The NCSBN has clearly communicated that educators do NOT need to reach the NCSBN model but use established practice-based models of teaching clinical judgment. Therefore, confidently use the nursing process and Tanner’s Clinical Judgment Model as your curricular frameworks and teach the 6 step NCSBN evaluation framework only in the last semester when preparing students for NCLEX. 

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.

Best Practices for Developing Clinical Judgment

Elizabeth Herron’s study Developing Clinical Reasoning in Undergraduate Nursing Students: Strategies to Promote Success revealed that graduates were better prepared for practice when active learning was used to develop clinical reasoning and that an emphasis on clinical reasoning should have begun earlier to better prepare students for practice. 

Make learning active! Tanner’s framework should be taught. It is a clinical reasoning framework that leads to the outcome of clinical judgment. 

Educator Resources

KeithRN case studies are 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!

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 as the foundation for nurse thinking in your curriculum and then building on this with Tanner’s Clinical Judgment Model, your students will be well prepared for both clinical practice and licensure including Next-Gen!

Learn more in this video: