What is included in the nurses ability to make a clinical judgement decision?

<2-min.> NCSBN's foremost expert on the Next Generation NCLEX discusses some subtle distinctions in verbiage regarding a new test to assess clinical judgment.

The following is a transcript of the above video conversation between Philip Dickison, PhD, RN, Chief Officer, Examinations, NCSBN, and Sheryl Sommer, PhD, RN, CNE, Vice President, Chief Nursing Officer, ATI.*
Several years, the National Council of State Boards of Nursing (NCSBN) began researching the topic of clinical judgment in the nursing profession. Its efforts identified the need to assess clinical judgment in nursing graduates using the organization's lauded licensure examination, the NCLEX.

But what is clinical judgment? We asked Dr. Dickison to explain.

Q: What’s the difference between clinical judgment and similar phrases, such as clinical reasoning, decision-making, or clinical decision-making?

A: These are words, but they need to be defined, okay? And so what we did was that there's this sort of combination of some new information in the cognitive science.

So, you have a lot of research on critical thinking and you have this new — well, not brand new, but new compared to other lines of cognitive — and it's called decision theory, right? And so we said, let's take a look at the combination of critical thinking and decision theory. And it is out of that that comes this thing called clinical judgment. I would argue that's probably just a name that is clinical reasoning. If someone is saying clinical reasoning, I generally stop and say, "What do you mean by that?" so I'm sure that we're all talking about the same thing, right? Or somebody says, "Clinicals are critical thinking." What do you mean by that? Because I need to know that we're talking about the same thing.  Generally, in my world, I would say — and I know that some others won't — but that we're talking about clinical judgment. It may be an umbrella of critical reasoning. I suggest that they're probably just saying it because reasoning requires you to go through the same steps as judgment. 

Clinical judgment = the final decision

Clinical reasoning = the process

Judgment suggests that that's the final decision; reasoning is the process. Maybe, at the end of this, we call it clinical reasoning. I don't know. We have chosen clinical judgment and have established an operational definition for it, so we all know that's what we're talking about.

NCSBN’s Operational Definition of Nursing Clinical Judgment:

An iterative decision-making process that uses nursing knowledge to:

• Observe and assess presenting situations
• Identify a prioritized client concern
• Generate the best possible evidence-based solutions in order to deliver safe client care.

*This discussion took place at that National Nurse Educator Summit in April 2018 in Salt Lake City.

DO YOU HAVE QUESTIONS ABOUT DEFINING CLINICAL JUDGMENT? ASK THEM IN THE COMMENTS BELOW.

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Volume 21, December 2016, Pages 280-293

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Clinical nursing environment

Cognitive reasoning skills

I remember the patient presentation like it was yesterday; it has been 20+ years. The elderly gentleman was wheeled into the ICU just as I was getting off the phone with a report from the nurse on the step-down unit.

He was pale, and his altered level of consciousness communicated in the report was obvious. As other nurses assisted me in placing his ECG leads, the BP cycled a second time. The CRNA on call happened to be on the floor, and I let the resident know that I’d like an arterial line and signaled the CRNA. As the arterial line was placed, I half-joked with the CRNA, “are you sure this is an ART line, not a SWAN?” as the reading was that low. I immediately assessed heart sounds, and there it was, the “whoosh, whoosh, whoosh,” the classic washing machine sound of a blown mitral valve.

I’d read about it, heard about it during a Laura Gasparis lead conference, but never heard it in real-time—but there was no doubt. My gut told me this patient needed surgery now.

I looked at the resident requesting an ultrasound and that the cardiothoracic team be called. She was not convinced of the urgency, to which I responded, “they need to be here now, trust me.” Reluctantly, she made the call. The surgery went well; the patient survived and later returned to the unit with treats and a “heartfelt” thank you. Not one of us took credit for that day—we simply said, “you are welcome.”

This “gut feeling” we call clinical judgment that results in sound clinical decision-making is not something we graduate with from nursing school. For me, it was the result of the nurse faculty who challenged me in the simulation and skills lab, with thought-provoking didactic classes, and most importantly, prepared me for clinical rotations.

There were days in nursing school I felt frustrated, disillusioned, scared, and even at one point wanted to quit. The faculty did not give up on me. I am forever grateful, and I remind them often to this day. It is their best practices that I recalled as I became nurse faculty.

As nurse faculty, we are tasked to educate nurse generalists. The new graduate should possess the requisite knowledge to pass the NCLEX and the requisite skills to begin practicing as a registered nurse. Imparting clinical judgment leading to clinical decision making and best patient advocacy skills is perhaps the most daunting yet most vital of these tasks.

What is clinical judgment?

To effectively and adequately impart clinical judgment, it is essential to have a working definition. Clinical judgment is the accumulation of knowledge and skills over time, which contributes to the nurse’s ability to analyze and synthesize the patient presentation, objective and subjective data, and then provide evidence-based nursing interventions to improve patient outcomes; clinical decision making. Clinical judgment also contributes to the nurse’s ability to respond to changes in patient presentations with sound clinical decision-making and patient advocacy.

It is important to remember that clinical judgment leading to sound clinical decision-making is a process. As faculty, we can foster student commitment to this process by establishing a baseline level of confidence in their ability to practice by placing them in safe simulation or clinical environments and empowering them to engage in lifelong learning.

These are several best practices we as faculty can provide to foster clinical judgment in our nursing students.

Provide safe opportunities that challenge critical analysis skills while making sure they know they are supported. Patient presentations, objective and subjective data can present fast and furious in the clinical setting. The use of case studies in the didactic setting and engaging simulation or skills lab beyond repetitive repeat demonstrations are two ways to integrate critical analysis into the curriculum. Frequent and repeated opportunities to make mistakes in the non-hospital setting can contribute significantly to student confidence as they see themselves successfully navigating complex scenarios.

Provide reflective debriefing opportunities. Allowing students a safe environment to discuss what went right and, more importantly, what went wrong can contribute significantly to student confidence which feeds into clinical judgment and decision-making. Be sure to allow the students time to respond to each other; to problem solve as nurse colleagues before interjecting as faculty.

Do not hesitate to take students out of their comfort zone. Challenge them in their clinical assignments. It is crucial to identify the students who consistently wish to watch or choose what they perceive as the “safe patient.”

Emphasize preparation. Be sure that students receive an orientation to a unit and, if possible, provide a pre-clinical introduction to their preceptor or other nurses who will be working during the clinical rotation. This can be done during a brief meet and greet. Establish a day and time before the official clinical assignment when students can gather in a break or conference room and invite the nurses an opportunity to meet the students over treats and coffee/juices, etc. After spending time with students on the floor, utilizing a scavenger hunt to locate essential items and areas. All this goes a long way to alleviate environmental fears of the unknown.

Pre-clinical assessment of student preparedness is essential as students invariably want to “hit the floor” often not knowing what they do not yet know or are prepared for. Students should be able to articulate patient diagnosis, anticipated presentation, prioritization of data collection and interventions. A valuable pre-clinical conference strategy can include “what if” scenarios. Challenge students with brief patient scenarios for which they will have to provide a clinical-decision.

Be a visible presence in the clinical setting. Students need to know they are supported and that you are available to them when they need you.

Do not underestimate the value of the post-clinical conference. This should be the safest of places where students can discuss what went well and what did not go so well. Work to create an environment that allows students to vent frustrations, identify strengths as well as weaknesses. Encourage students to problem solve amongst each other before you jump in to solve the problem. In this way, you are fostering their ability to learn from each other. This contributes to student confidence and, ultimately, clinical judgment and decision-making.

Finally, make the experience as fun as possible. Encourage students to find humor in their humanness - remind them that they were called to the profession and that they can become the nurse they envision themselves to be.