Clinical Judgment: Putting the Puzzle Together

by Susan Sportsman, PhD, RN, ANEF, FAAN

How do we help nursing students make good clinical judgments? That is the question that most of us struggle with. We “give” students the necessary knowledge in class through lectures, readings, and various learning activities. We provide opportunities to “practice” in simulation/labs and during their clinical experiences. We assign increasingly challenging nursing practice opportunities. As a result, many students learn to put the pieces together to make good judgments—most of the time. However, every novice nurse I have ever worked with has been worried about making a clinical mistake—mistakes which usually are driven by poor clinical judgment.

That certainly was my experience as a new nurse.  Working the 11-7 shift  (back in the day), I was the only RN on a 50-bed med-surg unit. (Admittedly hospitalized patients weren’t as sick then as they are now, but still…) My staff included an LVN with multiple years of experience and, on occasion, a CNA. My guardian angel must have been looking out for me, because my LVN colleague was not only experienced, but also kind and caring. I had the RN title, but I didn’t have sufficient confidence in my ability to come to a conclusion about the severity of many situations. My colleague never made me feel stupid and she always helped me understand the clinical context so I could figure out the appropriate next steps. For example, when faced with an immediate post-surgical patient who had some bleeding, I would say “How much bleeding is too much in this situation and when should I act?” She would always answer from her years of practical experience and her advice was always good. Needless to say, I am forever grateful for my colleague’s support!

Dr. Phil Dickison, Chief Officer of Operations and Examination at the NCSBN, says, “Ultimately no single element of clinical judgment (recognizing cues, developing hypotheses, taking appropriate action, and evaluating outcomes) adequately predicts a nurse’s clinical judgment ability.” (https://www.ncsbn.org/13342.htm) Rather, by appropriately combining the results of the components of the clinical judgment model, the nurse is able to provide safe and effective care. What I lacked at the time of my graduation (and I am surely not alone) was confidence in my ability to put the pieces of the puzzle together.

What, as faculty, can we do to better prepare students to complete the puzzle? Let’s turn to some advice from experts in the educational arena regarding problem solving (a part of the NCSBN Next Generation NCLEX Clinical Judgment Model) and use this in the context of nursing education.

The Centre for Teaching Excellence at the University of Waterloo in Ontario, Canada outlines some approaches for teaching problem solving that can be applied to faculty work with nursing students.

1. Help students understand the problem by discussing the “what” and “why” in order to find the answer to “how.” Often students (or novice nurses) don’t understand what the problem actually is. Take my earlier example of assessing a patient who is bleeding. The first problem the nurse in this situation must resolve is: What is happening with this client from a physiological perspective? Is it normal or abnormal? Is it an emergent situation or something to be watched? Answers to these questions will direct the nurse’s next step to provide safe care. Walking students through this approach by asking the “what” or “why” questions when discussing a clinical situation will help students think through the problem.

2. Help students to articulate the criteria for success. In our example, identifying the severity of the problem will help the nurse identify the action(s) to be taken. So the criterion for success for this initial problem involves identifying necessary assessment data in order to determine the level of risk to the patient. (Obviously, there will be many other clinical judgments that will subsequently be made in reacting to the clinical situation, but this priority problem illustrates the likely concern of the novice nurse.)

3. Ask questions and make suggestions. When a faculty asks students to predict, “What would happen if…” students have an opportunity to develop analytical skills in a safe environment. Our example again: What other symptoms might the client experience if the rate of the bleeding increased?

4. Link errors to misconceptions. Recognize that errors result from evidence of misconceptions rather than carelessness on the part of the student. Thus, if we can identify the misconception and help students make the connection with the correct information, students have the opportunity to analyze their own mistakes and learn from them.

5. Have the student problem-solve by talking through the problem out loud. This will slow down their thinking, allowing them to analyze the results of their problem-solving activities as they are formulating the solution.

6. Model your own expert thinking, but be careful to make explicit the strategies and techniques that the student (or novice nurse) would need to hear, even though these are often automatic for the expert.

7. Provide students with the opportunity to reflect on the approach to the problem they selected—-even if they were able to effectively address the problem. Specific questions faculty should ask students (so they can ultimately ask themselves) include:
• Does the chosen action(s) make sense?
• Does it fit with the criteria for success identified? Why or why not?
• Could the student have chosen another solution? How might a different solution affect the client’s care?
• What did the student learn by doing this? This is one question we should ask every time we interact with students.
Adapted from https://uwaterloo.ca/centre-for-teaching-excellence/teaching-resources/teaching-tips/developing-assignments/cross-discipline-skills/teaching-problem-solving-skills 

These strategies may be used in class with a large group of students, in small groups, and as a one-on-one interaction between the faculty and student in test-review or clinical discussions. The ultimate goal of these teaching approaches is to develop behaviors that students can integrate into their own clinical practice.

We must also recognize that a number of environmental factors in the actual clinical setting may interfere with the clinical judgement of the student (or novice nurse). For example, the complexity of the problem, time pressure (real or imagined), and/or unavoidable interruptions may prevent students from adequately applying the NCSBN clinical judgment model, even when in a typical learning situation, they would be able to do so (Muntean, 2017). To prepare students to learn to use the model, faculty must plan for time to slow down the learning process to allow students to learn and reflect. However, to prepare them for the work world, we must also provide opportunities, typically in lab or simulation, for students to experience the impact of these environmental factors on clinical judgment. This will prepare the student to reach a level of competency in their clinical judgment skills that future employers will require.

Development of our students’ clinical judgment is the priority task for nursing faculty. The NCSBN Next Generation NCLEX (NGN) project has highlighted the importance of this competence and is providing us with some context to ensure that our efforts with students are focused on this approach. In this blog, from time to time, we will continue to explore strategies to emphasize clinical judgment in our curriculum. Let me hear from you regarding your experience in supporting students to develop clinical judgment competence.

References

Creative Commons (2019) Teaching Problem Solving. Center for Teaching. Vanderbilt University https://wp0.vanderbilt.edu/cft/guides-sub-pages/problem-solving. Retrieved, March, 2019.

Creative Commons (2019) Teaching problem-solving skills. Centre for Teaching Excellence. University of Waterloo.  https://uwaterloo.ca/centre-for-teaching-excellence/teaching-resources/teaching-tips/developing-assignments/cross-discipline-skills/teaching-problem-solving-skills .    Retrieved, March, 2019.

Dickison, P. (2019) The Clinical Judgment Model. Next Generation News. Winter, https://www.ncsbn.org/13342.htm. Retrieved, March, 2019.

Muntean, W. (2017) Nursing Clinical Decision-making: A Literature Review
National Council of State Boards of Nursing
https://www.ncsbn.org/Nursing_Clinical_Decision_Making_A_Literature_Review.htm. Retrieved, March, 2019.

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