Nurses today work in increasingly complex environments, and have less time to spend with patients. They must make fast, accurate decisions, drawing from a variety of information sources. This application of critical thinking and decision-making is known as clinical judgment.
Strong clinical judgment skills are crucial for patient safety. In fact, studies have shown that up to 65% of adverse events in hospitals result from poor clinical decision-making, and could have been prevented. Unfortunately, many novice nurses do not have adequate clinical judgment skills. Kavanagh and Sharpnack examined newly graduated nurses in 2021, and found that an average of only 9% scored in the acceptable competency range for a novice nurse.
In order to help students better develop these crucial skills, the National Council of State Boards of Nursing (NCSBN) has created the Next Gen NCLEX (NGN). This updated nursing licensure exam includes new types of questions and case studies to assess clinical judgment skills in more realistic scenarios.
These questions were developed based on the NCSBN Clinical Judgment Measurement Model (NCJMM). NCSBN researchers developed the model through reviews of the nursing literature and ongoing dialogues with nursing experts. They also analyzed data from more than 200,000 NCLEX candidates.
The NCJMM was developed as a framework for valid measurement of clinical judgment and decision-making. In this article, you’ll learn about the five layers of the model, as well as some of the theories that support it. It’s useful to refer to the NCJMM diagram to understand the relationships between each component.
The NCJMM is divided into five layers, labeled Layers 0-4 that are built upon and expand the nursing process. Each layer connects to the previous layer and adds detail.
Layer 0 provides the situation in which clinical judgment is used. Layer 1 encompasses clinical judgment in its entirety. Patient needs come in from Layer 0, and as a result of clinical judgment, clinical decisions are made. Those go back to Layer 0, and address the original patient needs.
Layers 2 and 3 provide further refinement of the clinical judgment process. Layer 2 contains three stages, which are broken down into cognitive processes in Layer 3.
Layer 2 focuses on the iterative nature of clinical judgment. If the evaluation at the end is not satisfactory, then the process starts again with forming new hypotheses. If the evaluation is satisfactory, then the process ends with a clinical decision.
Layer 3 focuses on the steps that a nurse goes through in order to reach safe and effective clinical decisions. These steps are explicitly evaluated in the NGN exam.
Layer 4 provides the context for clinical judgment. It lists the environmental and individual factors that can affect a nurse’s clinical judgment abilities.
Layer 3 is the most important layer when it comes to preparing students for the NGN exam. The new case studies in the new exam contain six questions, each measuring one of the 6 cognitive skills needed for clinical judgment from Layer 3. Each of these processes is described in detail below.
Important cues about patient needs can come from many places, including the environment, observable symptoms, a patient’s answers to questions, vital signs, and medical records. A nurse must decide whether cues are normal or abnormal. They can use this information to determine which cues are the most relevant and important.
Once the relevant cues have been identified, a nurse analyzes them by connecting them to each other and possible conditions. This analysis allows the nurse to form multiple hypotheses about the patient’s condition.
The nurse must next prioritize these competing hypotheses based on factors like which one is most likely, most urgent, or most serious.
The nurse generates solutions to address the highest priority hypotheses. This can include gathering further information to allow the nurse to distinguish between competing hypotheses. It can also include determining interventions that would lead to desirable outcomes and avoid undesirable ones.
The nurse must then implement the chosen solution(s). This includes knowing how to perform or request any necessary procedures. It also includes knowing how to communicate and document the decisions and interventions. Interventions must take into account the environment and the needs and preferences of the specific patient.
Once an action has been taken, the nurse should evaluate the outcomes of the action. This involves comparing the observed outcomes to the expected outcomes. The nurse should identify signs of whether the patient’s status is improving, declining, or unchanged. If the patient’s status is declining or not improving as expected, this information should be used to start the clinical judgment process again with this additional information. The nurse can also reflect on the outcomes and consider whether other interventions might have been more effective.
The conditioning factors in Layer 4 provide the context that distinguishes clinical judgment in practice from the isolated and decontextualized facts that a nursing student initially learns. These factors are broken down into environmental factors and individual factors.
Consequences and risks
Level of experience
These conditioning factors are woven into the NGN exam case studies. They can appear in any part of a case study and could reappear multiple times. Nursing students should be aware of how these factors would impact the clinical judgment process. For instance, they should understand how resources differ in different patient care environments. This could determine which interventions are available in a particular scenario. They should also understand how time pressure affects the prioritization and implementation of possible solutions.
Layer 4 is where clinical practice is most relevant, providing the greatest preparation for the exam. This is where the quality of the clinical site makes a difference in preparing a nursing student for the NGN exam. Because clinical experiences vary in quality and can only expose each student to a small fraction of the situations they will encounter as nurses, it is helpful to augment their learning with high-fidelity simulation.
Teaching with an immersive VR simulation platform like UbiSim enables nurse faculty to customize each scenario, adding contextual factors that mirror the real-world challenges to clinical judgment that nursing students will encounter as nurses. UbiSim’s customizable scenarios enable nurse educators to tweak environmental factors in order to provide a tailored learning experience for the student and help build their clinical judgment.
Part of the beauty of VR simulation is that it empowers nurse educators to consider the individual factors of their students and tailor the UbiSim experience to their needs. For example, novice learners may need more preparatory activities to process new information prior to the simulation (and thus reduce their cognitive load), whereas advanced learners may only need to receive the learning objectives and can process the rest of the information as it is revealed during the simulation.
By wearing a VR headset and immersing themselves in UbiSim’s virtual nursing environment, students have a safe space where they try, fail, and try again as they work to provide patient care. Nurse educators can assign scenarios to nursing students both individually and in multiplayer mode, where students build collaboration and communication skills as they work together to improve patient outcomes. Following the simulation experience, students follow the PEARLS debriefing framework and receive a recording of their session with feedback for further growth from UbiSim.
Each UbiSim scenario needs assessment aligns with the NCLEX Test Plan Categories, the NCSBN Clinical Judgment Measurement Model, and AACN Essentials Core Competencies for Professional Nursing Education.
To find out how UbiSim’s engaging nursing simulations prepare students to pass their licensing exam and practice as effective nurses, book a consultation.
The researchers at NCSBN used several existing theories in the development of the NCJMM. One was the Information Processing theory. They used this theory to break the complex clinical judgment process down into the cognitive elements that are required for decision-making like we see in Layer 3. These components are distinct but still influence each other.
The Information Processing model assumes that the decision maker — in this case, the nurse — uses short-term and long-term memory. Short-term memory is limited, but long-term memory is unlimited. These two types of memory interact when making decisions. In this theory, decision-making is broken down into the following components: cue acquisition, hypothesis generation, cue interpretation, and hypothesis evaluation.
The researchers also relied on the Intuitive / Humanistic theory when designing the NCJMM. This theory focuses more on how an individual’s decision-making process changes as they gain expertise. It proposes that people become more efficient and intuitive in solving problems as they become more experienced.
There are five levels of experience in this theory: novice, advanced beginner, competence, proficiency, and expertise. Each level characterizes a different type of decision-making process.
Newly licensed nurses should be at least at the advanced beginner level. For this reason, the Next Gen NCLEX uses case studies and clinical judgment questions that require candidates to take context into account when making decisions about realistic nursing scenarios.
The NCSBN Clinical Judgment Measurement Model (NCJMM) allows the National Council of State Boards of Nursing to assess candidates’ clinical judgment in a structured and reliable way. One of the best ways to prepare nursing students for the clinical judgment questions in the NGN exam is to give them plenty of chances to apply their nursing knowledge in realistic situations. Immersive virtual reality simulations can provide great opportunities to practice clinical judgment.