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CHAPTER 2 Clinical Judgment
level, and the type and number of prior experiences. For example, a novice nurse with a limited knowledge base and little to no patient experience will encounter difficulty in analyzing essential cues of a deterioration in a client’s condition. This nurse should be working with a preceptor or seek assistance to ensure safe cli- ent care. In contrast, environmental factors identify influences, such as the physical environment, avail- able resources, time constraints, task complexity, and cultural considerations. For example, a nurse who has never changed a central line dressing (a complex task) may not understand the importance of or may devi- ate from infection-prevention measures. This nurse should be mentored throughout the process. ■ Layer 3 requires you to have a solid knowledge base to recognize patterns, understand connections between cues, examine pathophysiological processes, organize data, and relate data back to the client’s problems. It involves an independent recurring and repetitive processes of recognizing and analyzing cues from different sources (e.g., signs and symptoms, medical history) to form and refine hypotheses in layer 2. The nurse then prioritizes the hypotheses and generates solutions by determining desired outcomes and the best interventions to achieve them. Next, actions are implemented, and finally, outcomes are evaluated. When actual outcomes deviate from those expected, the process will restart. Key Point: The failure to recog- nize cues is a major detriment to making sound clin- ical decisions because significant factors are omitted from the subsequent processes (e.g., analyzing cues,
formulating hypotheses). The nurse’s professional and personal experience can influence what cues are rec- ognized; thus, self-knowledge is important. ■ Layer 2 involves forming, refining, prioritizing, and evaluating hypotheses to achieve the desired out- comes. This may involve repeated cycles, depending on one’s experience level. Novice or new nurses may have multiple cycles, whereas experienced nurses may immediately formulate the more appropriate hypothesis. Layer 2 requires a refined scientific, theo- retical, and practical knowledge base. ■ Layer 1 comprises the outcome, which is clinical judgment. ■ Layer 0 is the clinical decisions made by the nurse to address the client’s needs. With continued clinical experiences, you will rec- ognize patterns and more easily make connections between cues, theoretical knowledge, and client care decisions. As you gain more clinical experience, your abilities in layers 2 and 3 will become less deliberate and analytical and more intuitive. You will become more confident and accurate in your abilities to rec- ognize and analyze cues; form, refine, and evaluate hypotheses; and generate solutions to address your cli- ents’ needs. Let’s examine how use of the model would have been beneficial to Jan in the care of Mr. Anderson (Explore Your Nursing Role; see Table 2-2). Jan would need to have the knowledge to engage in the essential tasks in layer 3 to facilitate clinical decisions to meet the needs of Mr. Anderson.
Table 2-2 ➤ National Council of State Boards of Nursing (NCSBN) Clinical Judgment Model (CJM) Application
NCSBN CJM LAYER 3 Contextual factors
KNOWLEDGE AND CONTEXT FACTORS ■ Novice nurse, newly admitted postoperative client, medical-surgical unit, 5 other patients, family member present
EXPECTED BEHAVIORS/ACTIONS ■ Self-knowledge (recognize competency level; deficits in knowledge; time pressures, prior experiences, client presentation) ■ Know available resources ■ Recognize changes in vital signs as abnormal ■ Recognize signs and symptoms of shock ■ Identify diabetes, obesity, dementia condition ■ Identify effective handoff report (SBAR)
■ Postoperative abdominal patient ■ Drains (nasogastric tube, wound, Foley) ■ IV fluids ■ Changes in vital signs ■ Comorbidities (diabetes,Alzheimer, obesity, hypertension)
Recognize cues
■ Changes in skin color and moisture ■ Changes in level of consciousness ■ Laboratory values ■ Handoff report
(Continued)
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