Linda's Blog

Why the NCSBN’s CJMM Alone Cannot be Used to Teach Clinical Judgment

Subscribe to Unlock This Content

Enter your info below for access to all of Dr. Caputi's blog articles.

Invalid email address

Linda@LindaCaputi.com

For decades the nursing process was used by educators to teach nursing students to think. After decades of use, it was determined the nursing process failed to encompass the complexities of clinical judgment and the factors that influence clinical judgment (Dickinson, Hearling, & Lasater, 2019). What kind of thinking was supposed to happen in each step? Students are left on their own to figure that out. Faculty try to help, but without a specific approach, each faculty uses their own explanations and language. This inconsistency in teaching the detailed thinking needed in each step of the nursing process left the student unsure about how to think or, worse, they were oblivious to the fact that detailed thinking processes were needed to make the best decisions.

The Tanner Clinical Judgment model was presented in 2006 as a way to remedy this weakness with using the nursing process. The issue with the Tanner model is that it, too, did not offer any detailed, specific thinking. It replaced the 5 steps of the nursing process model with 4 steps of clinical judgment.

Around 2015 the National Council of State Boards of Nursing introduced their Clinical Judgment Measurement Model (CJMM). Although the National Council of State Boards of Nursing has stress that their Clinical Judgment Measurement Model (CJMM) is a measurement model, most vendors selling products and many conference speakers use it as a way to teach clinical judgment. The major issue is that the NCSBN CJMM is meant to measure the accuracy of decisions aligned with one of the six cognitive processes NOT to measure if students know how they use thinking to make those decisions. The CJMM was not designed to measure answers that reflect a particular clinical judgment cognitive process, not to teach clinical judgment. The CJMM is intended for high-stakes testing (NCLEX®) to measure the candidate’s ability to use clinical judgment, and not for teaching (Dickison, Haerling, & Lasater, 2020). Therefore, you must actually teach students to think using a teaching framework that supports the thinking required for the CJMM (Tyo & McCurry, 2019).

Let’s Reflect

Let’s sort out what the goal might be for adopting products that use the NCSBN’s six cognitive processes as a way to categorize practice case study test questions. The goal of these products is to demonstrate how questions can be categorized using the NCSBN’s CJMM. The goal is not to teach clinical judgment although the marketing materials often claim this is the goal. It is imperative for nurse educators to review all adopted materials and make their own conclusions about what products are capable of doing or not doing. My conclusion is these products do not teach clinical judgment, but provide practice NGN test items that are categorized according to the six cognitive processes of the NCSBN CJMM. That is it! If your objective is to provide practice questions organized in that manner, then use the product. However, if your goal is for students to learn clinical judgment, that would not be the product to meet that goal.

What’s Missing?

So, what is missing? The detail is missing! How does the student know what kind of thinking to do in each of the six cognitive processes? Think of it this way. Would you tell a new driver to get in the car, turn the car on, back out of the driveway, put the car in drive, drive to the destination, and park the car? How will the new driver know what to do to safely back out of the driveway, drive to the destination, and park the car? The six cognitive processes of the CJMM provide the overall structure of thinking, but it does not provide the details of what to do in each category of thinking. Just like it is not safe to let the new driver “figure it out” from themselves, neither is it safe to let nursing students “figure it out” for themselves.

In both the 2021 and 2022 NCSBN’s NCLEX® conferences, it was shared that just teaching the steps of the nursing process without a CJ framework isn’t enough. The 5 steps are too general. The steps of Tanner’s model and the six cognitive processes of the NCSBN CJMM represent the same situation – too general, no detail. These models represent major categorizes of thinking, but lack detailed thinking processes. It is critical for faculty to realize this. Just teaching students by aligning case study questions or organizing care planning around the six cognitive processes does not teach clinical judgment. All that approach does is tell students they must use a particular cognitive process to answer the question, but how? What specific thinking is the students expected to do when “recognizing cues” so they actually get to the point of being able to recognize cues.

Consider the following table:

  The Caputi Clinical Judgment FrameworkNCSBN CJ Measurement Model Cognitive Processes  Nursing Process  Tanner’s CJ Model
1. Getting the Information  Recognize Cues  Assessing  Noticing
2. Making Meaning of the Information  Analyze Cues  Diagnosing  Interpreting
3. Determining Actions to TakePrioritize Hypotheses Generate Solutions  PlanningNo step in the Tanner Model
4. Taking ActionTake ActionsImplementingResponding
5. Evaluating Outcomes and Your Thinking  Evaluate Outcomes  Evaluating  Reflecting

Now consider this table with some detailed thinking competencies added:

Major Steps in the Caputi Clinical Judgment Framework Aligned with the NCSBN Clinical Judgment Measurement Model and the Nursing Process  The Caputi 2022 Clinical Judgment Competencies
1. Getting the Information
(NCSBN: Recognize Cues)
(Nursing Process: Assessing)
1. Determining important information to collect
2. Scanning the environment
3. Identifying signs and symptoms
There are 2 more.
2. Making Meaning of the Information
(NCSBN: Analyze Cues)
(Nursing Process: Diagnosing)
1. Clustering related information
2. Identifying assumptions
3. Recognizing inconsistencies
4. Distinguishing relevant from irrelevant information
There are 5 more.
3. Determining Actions to Take
(NCSBN: Prioritize Hypotheses and Generate Solutions)
(Nursing Process: Planning)
1. Managing potential complications
2. Setting priorities
There is 1 more.
4. Taking Action
(NCSBN: Take Actions)
(Nursing Process: Implementing)
1. Determining how to implement the planned interventions
2. Delegating
There are 2 more.
5. Evaluating Outcomes and Your Thinking
(NCSBN: Evaluate Outcomes)
(Nursing Process: Evaluating)
1. Evaluating data
2. Evaluating and correcting thinking

See the difference?

The Caputi Clinical Judgment Framework is the only clinical judgment model available that teaches all the detailed thinking required to implement the NCSBN’s CJMM and the Nursing Process. It is important to remember that students do not enter the nursing program knowing how to think like a nurse – it is the program’s responsibility to actually teach students to think like a nurse. I remember attending faculty meetings where I taught, and faculty teaching students in the last semester of the program reporting: “These students don’t know how to think.” Imagine that! Declaring students who are about to graduate do not know how to think! Remember, students think how we teach them to think. If, by the end of the nursing program, students are not able to engage in the thinking needed for safe nursing care, it isn’t necessarily the students’ fault, but a weakness in the program curriculum.

For example, the student emerges from a patient’s room and explains to the faculty what they will do. At this point the student should explain – in terms of thinking – how they arrived at what they will do. They would start with, “When I first walked in the room I scanned the environment and noticed……; then taking information from report and what I observed in the room, I determined important information to collect included…..” Students must not just explain the nursing knowledge/content they used, but what thinking they used as they determined what content to apply. This is thinking nurses do all day long, but never learned in a structured formal way because the language was missing. We now have the language!

Remember the Goal

All the research over the last 10 years on new graduates’ ability to engage in clinical judgment is dismal (Kavanagh & Sharpnack, 2021; Kavanagh & Szweda, 2017; Muntean, W. J. (nd)). The latest findings report that only 9% of new RN graduates can think at entry level expectations regardless of the level of education – ADN, Diploma, or BSN. This clearly indicates that the old way of teaching thinking is not working, which was: lots of questions, case studies with a focus on what content is important, Socratic questioning, etc. These teaching strategies are not effective for the purpose of teaching students to think. These teaching strategies can and should be used to apply the thinking of clinical judgment, but not to teach clinical judgment. The goal of the NGN was to measure the graduates’ ability to engage in clinical judgment. NCLEX® pass rates for both RN and PN/VN graduates increased with the introduction of the NGN.

Questions: Did the NGN reach its goal? Does the NGN serve as a “gate keeper” and only those graduates who learned and can use clinical judgment are passing the exam? Or, does the NGN actually measure clinical judgment? Did the change to partial credit scoring inflate pass rates? Only further research will answer these questions.

Students must learn to think in a different way to provide safe patient care that results in improved patient outcomes. The reason to teach clinical judgment is to teach students how to think to make safe patient care decisions! Thattype of thinking is also needed to pass NCLEX®, but the primary goal is safe patient care!

It is unknown if further research reveals that graduates passing the NGN may not be good thinkers. So, teaching student how to answer NGN questions by using the CJMM is not helping meet the primary goal.

Teaching the detailed thinking processes needed for quality clinical judgment meets both goals: Passing the NGN AND making safe patient care decisions.

All nurse educators must provide the type of teaching needed for students to actually learn clinical judgment. Just passing the NCLEX® has not, and likely will not, be a guarantee that our students are able to engage in quality decision-making.

Teaching a Detailed Clinical Judgment Framework

There has never been a textbook that actually teaches a detailed, focused clinical judgment framework. I have used a detailed clinical judgment framework in my work with schools for over 20 years. Originally, I focused on the detailed thinking skills arranged according to the 5 steps of the nursing process. In 2006 I connected the nursing process to Tanner’s Clinical Judgment Model and related my “thinking skills” or clinical judgment competencies to the steps in that model. Both the nursing process and Tanner’s model were not about teaching detail; just major categories. Tanner’s model was merely 4 steps and that was it – no specific, detailed thinking. Therefore, it was still necessary to teach using my framework even if Tanner was the adopted clinical judgment model. With the introduction of NCSBN’s clinical judgment measurement model, it was obvious the Tanner Clinical Judgment Model was missing a crucial step so I revised my framework to move away from Tanner’s with my current framework that uses 5 steps and 23 clinical judgment competencies.

All students should learn the detailed thinking taught using the Caputi Clinical Judgment Framework and how to apply it to patient care as well as using it to work through other issues/problems on the care unit. Then all faculty will use this approach to apply the clinical judgment framework in the classroom, clinical, and post-simulation debriefing – anywhere a nurse uses thinking. Consistent use of the clinical judgment framework by all faculty is critical for students to learn the thinking required on the Next Generation NCLEX®, but most importantly, for safe patient care. Students must learn a clinical judgment framework and apply it to nursing care throughout the nursing program for the goal of becoming “self-directed” thinkers by the end of your nursing program.

This framework is also used when learning pathophysiology and pharmacology. Students must use the thinking to determine how that content is applied to a specific patient situation. Just explaining the pathophysiology is not enough; students must learn how to use what they know about pathophysiology for that particular patient situation by applying thinking processes. The same is true for pharmacology.

Here’s the Detail

The Caputi Clinical Judgment Framework teaches the specific, detailed thinking of each step of the nursing process and each of the NCSBN’s Clinical Judgment Measurement Model cognitive processes. This has always been the BIG missing piece. Faculty must drill down to the detailed thinking and walk students step-by-step through that thinking as they learn each clinical judgment competency (thinking skill). Preferably, this detailed framework is taught in the first term of a nursing program, then ALL faculty use the language of that framework as they engage students in clinical judgment throughout the entire program. This is the only way to get to the detail of what needs to be learned about clinical judgment and for students to become self-directed thinkers by completion of the program.

At a pre-pandemic QSEN conference I attended, Dr. Kavanagh from Cleveland Clinic discussed the research she conducted on new graduates’ thinking abilities. She stated that new graduates are often very good at recalling information about an identified problem. The issue was they could not think beyond recalling information. New graduates struggled with thinking that required: determining what additional information should be collected; how much “wiggle room” around a normal value is reasonable for a particular patient situation; predicting potential completions; and transitioning their ability to think to a new situation they had not previously learned about.

The Caputi Clinical Judgment Framework teaches the specific, detailed thinking of each step of the nursing process and each of the cognitive processes of the NCSBN’s CJMM. This has always been what was missing when teaching nursing students to “think like a nurse”. Faculty must drill down to the detailed thinking and walk students step-by-step through that thinking as they learn each clinical judgment competency.

Important Note

This change is not difficult or radical – it involves a fine “tweaking” to focus on students actually learning clinical judgment, then using clinical judgment competencies (thinking skills) rather than answering faculty-directed, content focused questions. The thinking students use is what should lead them to the specific nursing content and patient information to use to make decisions. Why? Because that is what nurses must do – they must consider a situation then use thinking to determine what content needs to be applied to this patient situation – not just recall what they learned about a specific disease process or nursing skill. Registered Nurses providing patient care do not have faculty asking questions such as, “Did you check the A1C level?” or “Did you read the patient’s H&P?” The nurse must determine what questions to ask themselves based on the thinking they are capable of using. That is the goal of teaching clinical judgment. That is the heart of the change that needs to be made. That is what the Caputi Clinical Judgment Framework is all about.

In Conclusion

It is critical to remember that clinical judgment is just as important as content for passing the NCLEX® – and not just for NGN questions. The NCSBN has always stated that “critical thinking” is needed throughout the exam, even with the “old” types of NCLEX® questions. The current ways many advocate for teaching clinical judgment are similar to those that have been used for decades. All the research in the last 10 years demonstrates the decades-old approach is not working. It is critical that faculty commit to making a change in their teaching to embrace this new approach to teaching clinical judgment. When taking the NCLEX® students will need to be able to apply content to an individual patient situation by using clinical judgment, not just count on their ability to recall memorized content. This is true for ALL items types, not just the new NGN questions. As previously noted, this change is not difficult or radical. This change is just not what is popular so many faculty are not aware of how to implement such a change.

References

  • Dickison, P. Haerling, K., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical Judgment Model into Nursing Educational Frameworks. Journal of Nursing Education, 58(2), 72-78. doi:10.3928/01484834-20190122-03
  • Dickison, P., Haerling, K. A., & Lasater, K. (2020). NCSBN clinical judgment measure model clarification, Journal of Nursing Education, 59(7), 365.
  • Kavanagh, J. M., Sharpnack, P. A. (January 31, 2021) Crisis in competency: A defining moment in nursing education, OJIN: The Online Journal of Issues in Nursing, 26. (1), Manuscript 2.  DOI: 10.3912/OJIN.Vol26No01Man02
  • Kavanagh, J. M., & Szweda, C. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses’ clinical reasoning. Nursing Education Perspectives, 38, (2), 57-62.
  • Muntean, W. J. (nd) downloaded from: https://www.ncsbn.org/public-files/Nursing_Clinical_Decision_Making_A_Literature_Review.pdf
  • Tyo, M. B., & McCurry, M. K. (2019). An integrative review of clinical reasoning teaching strategies and outcome evaluation in nursing education, Nursing Education Perspectives, 40(1), 11-17.