An important student learning outcome for all nursing programs is to produce graduates with sound clinical judgment. The National Council of State Boards of Nursing (NCSBN) recognizes the critical role of clinical judgment and has developed the Clinical Judgment Model (CJM) and Next Generation NCLEX question types. The new questions evaluate the graduates' ability to make sound clinical judgments, and this is equated to the ability to deliver safe, competent nursing care.1
Teaching Clinical Judgment
Nurse educators are charged with the daunting task of teaching students how to make sound clinical judgments. A first step is to educate nursing students about clinical judgment as a process using an evidence-based framework such as NCSBN-CJM.1 The third layer of the model focuses on 6 cognitive processes a nurse uses in making clinical judgments: recognizing cues, analyzing cues, prioritizing hypothesis, generating solutions, taking action, and evaluating outcomes.1 Teaching strategies targeting the third-layer concepts threaded throughout the curriculum can foster students' clinical judgment development.2 Structured learning activities that help students connect theoretical concepts to actual clinical practice situations are valuable in teaching students how to make effective decisions and fostering readiness to practice.
Development and Implementation of the Clinical Preparation Tool
Clinical preparation is a time-honored teaching strategy in nursing education. As faculty appreciate the importance of clinical preparation and teaching clinical judgment, the existing clinical preparation tool in one nursing program was revised using the NCSBN-CJM1 highlighting Tanner's3 phases of clinical judgment to foster development of this skill among nursing students.
Students assigned clinical practice experiences on medical-surgical nursing units in our nursing program complete 5 clinical learning activities, or clinical preps, in a 7-week rotation. Students typically complete 1 prep weekly, allowing time for faculty to give written feedback prior to submission of the next. Preps are graded using a rubric and contribute 10% to the overall corresponding course grade.
Prerecorded training sessions on the CJM and a walk-through of a completed example prep are provided for faculty and students. Faculty training includes grading with the rubric. The clinical preparation tool and example were piloted in 1 course and have undergone several iterations incorporating feedback from clinical faculty and students, resulting in the inclusion of more prompts and explanations.4 The tool is provided in Supplemental Digital Content 1 (available at: http://links.lww.com/NE/B186), and an example using the tool is provided in Supplemental Digital Content 2 (available at: http://links.lww.com/NE/B187). Students arrive an hour prior to start of the day to familiarize themselves with their assigned client. A worksheet has been developed to guide students' thinking and data collection prior to and while caring for the client, ensuring students gather the information needed to complete the clinical prep after the clinical experience.
The objective is to provide guided practice directing students to think deeper. The prep offers opportunity for the faculty to evaluate students' ability to think like a nurse because their thoughts are now visible in text.4 First, students collect data from the electronic health record (EHR) including primary and secondary diagnoses, relevant past medical and surgical history, and provider orders. To demonstrate an understanding of the client's clinical situation, students complete a table providing evidence to support the primary diagnosis. This requires students to identify and link relevant subjective and objective data appropriately. Students research the EHR and review the admission history and physical, nursing and provider notes, and diagnostic and laboratory tests to sort through information to uncover supporting evidence.
On page 2, students explain the pathophysiology of the primary diagnosis. They identify 2 priority client teaching needs and anticipated discharge needs. Students list abnormal laboratory and diagnostic tests with potential rationale and how they are being addressed. Students then identify trends in data and those that would require monitoring. Students also list medications including generic and brand names, dose, route, frequency, classification, and action in their own words. To demonstrate recognition of prioritized, relevant information, students are prompted to concisely describe why the client is prescribed each medication and to list 3 most common side effects and 3 priority nursing implications.
Page 4 begins the heart of the clinical judgment learning exercise. At the top of the table, students list the primary medical diagnosis or priority clinical problem and related nursing diagnosis. The table is divided into 4 sections or rows labeled along the left-hand column: noticing, interpreting, responding, and reflecting coinciding with the 4 phases of Tanner's CJM.3 The table consists of 3 more columns: before (caring for the client), after (caring for the client), and comparison to what was expected using references such as textbooks or guidelines and/or other experiences with previous clients with the same problem. The first column listing Tanner's CJM phases contains prompts using language from Tanner's CJM, the NCSBN-CJM, and the nursing process to help students understand what information to provide.1,3
Before caring for the client, students complete the before column for noticing, interpreting, and responding on their worksheet. Under noticing, students list subjective and objective data they plan to collect, thus demonstrating an understanding of key, relevant cues to ascertain. As students collect data, they begin interpreting the information. As students analyze cues, patterns emerge, irrelevant information is sorted out, hypotheses are made, and students list prioritized actual problems, potential complications, and safety risks in the interpreting section. Then, students formulate a plan for responding and list expected nursing actions to address the problem and prevent potential complications and safety risks. Students note what actions can be delegated and to which member of the health care team.
Students are now ready to engage in client care. Students receive bedside handoff, evaluate the client, and then discuss findings with the clinical faculty. During this exchange, the clinical faculty member evaluates the student's overall understanding of the client's situation and plan of care.
After caring for the client, students complete the after column for the noticing, interpreting, and responding. In the noticing section, they describe actual assessment findings and in the responding section actions taken. In the interpreting section, a final prioritized problem list, potential complications, safety risks, and client goals are identified, as well as actions taken to prevent or monitor for each. In the comparison to column, students cite evidence from references to support the plan of care or share prior experiences with clients with the same diagnosis and how that client's clinical presentation and/or care was similar to or different from this client.
The reflecting section, also completed after caring for the client, is dedicated to evaluation and is divided differently from those of the others. The columns are labeled: reflecting-in-action, reflecting-on-action, and comparison to. While reflecting-in-action, students might share an unexpected situation that arose such as a client who developed sudden shortness of breath. Students would list assessments requiring ongoing monitoring and what actions were taken to address the unexpected event. Reflecting-on-action involves evaluating client outcomes, addressing changes in the client's condition based on the care provided and any new problems that developed. Students also reflect on their own performance and what they would do differently in the future if a comparable situation arose.
The clinical prep is a clinical judgment-directed learning activity applied to actual clients and serves as an assessment tool. Repeated, consistent learning opportunities using a framework such as the CJM allows students to practice the clinical judgment process and may lead to improved clinical judgment, adequate preparation for practice, and Next Generation NCLEX.2,4
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