With all the rhetoric about the need to learn clinical judgment focused on preparation for the Next Generation NCLEX, the many benefits of engaging in sound clinical judgment may not be appreciated.

Consider this scenario:

A nursing faculty approaches a student in the clinical setting. The student does not look well, so the faculty asks, “What’s wrong?” The student states she was in the patient’s room and the patient became very distressed, grabbing her abdomen and crying, then began yelling at the student. The student reports she panicked and fled the room when she noticed the nurse in charge was approaching the patient. The student remained very upset for the next hour, so the faculty suggested the student leave the clinical site for the day and get some rest. The next day the faculty meets with the student to console her and assure her that she will be better able to deal with these situations once she gets more experience. Unfortunately, this hopeful outlook for the student’s future may not materialize and leaves to chance the student’s ability to learn to deal with these unexpected situations.

This student was unable to deal with the stressful, unexpected occurrence, but was also unable to recover from the event and refocus on the care she was assigned to provide. She left the clinical site discouraged and ashamed.

Now we have to ask:

1. What happened?
2. Why was the student unable to focus on this patient’s situation?
3. Or, at the very least, why was she unable to regain her composure, regroup, and engage in her remaining patient care responsibilities?
4. Equally important, what can faculty do to help students handle these types of situations?

The reason the student was unable to focus on, and deal with, the situation in the moment is likely because the student had not learned to be resilient. Remember stress theory and the Fight or Flight phenomenon (the acute stress response)? This student took flight.

This is an extreme example of a student’s lack of resiliency, but it happens many times (albeit to a much lesser degree) when students are learning in the clinical environment. What can faculty do to help?

In my consulting work and talking with CNOs of institutions that hire new nursing graduates, I have discovered that one of the major issues identified is that new graduates are not resilient.

Let’s look at what resilience is, how it connects to clinical judgment, and what faculty can do to help nursing students become resilient.

Sieg (2020) defines resilience as “the capacity to accurately perceive and respond well to stressful situations” (para. 2).

The healthcare environment can, at times, be a very stressful place. Healthcare settings are very dynamic environments; circumstances can change often and very quickly. The unexpected can happen without warning. The nurse must be ready to respond immediately. Responding immediately means staying calm and having a process for thinking through problems to focus your thinking during stressful situations. Self-directed thinkers remain in control of their thinking by using a clinical judgment framework to guide their thinking in the moment and keep them mindful. Nurses who are self-directed thinkers are more resilient than nurses who are not able to control and focus their own thinking. Being resilient and in control of your thinking is the first step to responding well to stressful situations.

Faculty can help students focus their thinking by using the Caputi Clinical Judgment Framework which requires students to be mindfully engaged in their thinking. Sheridan (2016) defines mindfulness as “the ability to be fully present and attentive in the moment” (p. 29). To be fully present in the moment has become more difficult in today’s world. People are constantly interrupted by the ding of their cell phones indicating a new email, text, or voicemail. Even though it appears the person with the phone alert continues with their actions seemingly unaffected, that person is likely thinking about who the message is from or what the message might say. In today’s world, the mind is constantly pulled away from the task at hand. It may be easy to remain mindful for a few seconds; the key is to stay mindful. Staying mindful has been shown to lower stress, protect health, and lift mood (Hanson, 2018).

But how can a person stay mindful in an unexpected, stressful situation? It can be difficult to stay mindful in stressful situations which may occur during patient care. However, staying mindful is critical for safe patient care. Practicing mindfulness builds resilience and being mindful means having a planned approach to guide your thinking. Applying a planned approach to thinking helps focus the thinking process to keep attention on the patient and the situation at hand.

Nurses must be mindful, present, and engaged with the patient. Using the Caputi Clinical Judgment Framework and working through the clinical judgment competencies provides a way for students to stay grounded because they are using a thinking process to ensure clinical judgment is skillfully implemented.

The clinical judgment framework serves as a guide that gets students back on track with their thinking when momentary distracted or interrupted–it helps the student focus on what is happening and to cope better with distractions. This ability to focus (mindfulness) is basic to becoming resilient, a state in which the student will be able to accurately perceive and respond well to stressful situations by using learned clinical judgment competencies.

What can faculty do?

Faculty can teach students to focus by using a detailed clinical judgment framework that includes thinking skills (clinical judgment competencies) and not just general headings. General headings such as “Recognize Cues” or “Analyze Cues” is not enough.

For example, there are 6 cognitive processes the NCSBN will use to measure clinical judgment on the Next Gen NCLEX. These 6 cognitive processes are:

1. Recognize Cues
2. Analyze Cues
3. Prioritize Hypotheses
4. Generate Solutions
5. Take Actions
6. Evaluate Outcomes

Instructing the student to “Recognize Cues” without teaching the detailed thinking processes that make up that larger cognitive process does not prepare students to think. The student must have learned, and practiced using, specific thinking skills (clinical judgment competencies) to guide their thinking related to “Recognize Cues”. Here are the 5 clinical judgment competencies used when a student “Recognizes Cues”.

Getting the Information (Recognize Cues): 5 clinical judgment competencies:

1. Determine important information to collect
2. Scan the environment
3. Identify signs and symptoms
4. Assess systematically and comprehensively
5. Ensure accurate information

Students learn these 5 clinical judgment competencies and practice using them over and over in their nursing studies in the clinical, simulation lab, and when working through case studies. This is how they learn to “recognize cues”. With practice the detailed thinking becomes automatic. That is the goal—the student will automatically use the thinking when needed in all situations, and certainly when unexpected occurrences happen.

If the student in the scenario was well-versed in a clinical judgment framework with specific thinking skills (Clinical Judgment Competencies) she would have been better prepared to focus her thinking, remain mindful, stay with the patient, and begin to implement the thinking process to collect needed information used to determine what might be wrong and what to do. Students need to learn a clinical judgment framework and have lots of practice using it so it will be used automatically. Nurses use automatic thinking; students do not, but can learn to do so.

The student in the scenario was not able to focus because she did not have a plan for doing so. She was lost about what to think and how to think, and succumbed to feelings of being incompetent and not knowing what to do. Her mind focused on her lack of ability rather than on how to think about the situation. This is a terrible place for students to be.

Learning a complete clinical judgment framework prepares students with a way to focus their thinking to do what they need to do rather than flee the situation.

Using specific clinical judgment competencies organized in a framework keeps the nurse focused. Focused thinking is a characteristic of mindfulness; mindfulness contributes to resiliency. A resilient nurse is able to accurately perceive (read and understand) a situation, stay calm, remain in control of their thinking, and respond well in stressful situations.

Let’s look at the topic of clinical judgment as more than a way to prepare students for the Next Generation NCLEX, but also as a way to prepare students with the clinical judgment competencies they need when faced with unexpected occurrences. This has become a major responsibility of nursing faculty and now we know how to do it!

Note: Much of the content in this blog are excerpts from Think Like a Nurse: The Caputi Method for Learning Clinical Judgment.

Hanson, R. (2018). Resilient. Harmony Book.

Sheridan, C. (2016). The mindful nurse: Using the power of mindfulness and compassion to help you think in your work. Rivertime Press.

Sieg, D. (2020). 7 habits of highly resilient nurses, Sigma Theta Tau Nursing Center. https://nursingcentered.sigmanursing.org/features/more-features/Vol41_1_7-habits-of-highly-resilient-nurses