Developing clinical judgment skills in nursing students

Critical thinking

To develop critical thinking skills, students must engage in activities that encourage analyzing, discriminating, information-seeking, and open-mindedness. Critical thinking requires a student to think clearly, precisely, and accurately and act on what they know and understand; critical thinking precedes clinical reasoning (Manetti, 2018; Potter & Perry, 2012; Alfaro-LeFevre, 2017).

Clinical reasoning

Clinical reasoning involves a student's ability to apply knowledge, think in action, and reason as a situation changes over time (Benner, et al., 2010). the analysis of data is done through four steps:

1. noticing relevant clinical data
2. interpreting the clinical significance of data
3. responding appropriately by prioritizing responses and actions
4. reflecting on the effectiveness of the response (Tanner, 2006).

Clinical judgment

Clinical judgment results in a student's conclusions after making a holistic assessment that correctly interprets clinical data to determine the best response. It is an outcome that depends on critical thinking, clinical reasoning, and intuition (Rischer, 2021). 

In nursing, for example, strong clinical judgment involves a nurse choosing the best response among alternative actions in light of expected outcomes, using ongoing evaluative reflection to monitor a patient's response, and then modifying interventions accordingly. Reflecting on clinical decisions afterward leads to improved judgment when caring for future patients (Alfaro-LeFevre, 2017; Tanner, 2006; Manetti, 2019).

Clinical judgment models for nursing instruction

Nursing Process (American Nurses Association)

• Assessment — the nurse assesses patients on an in-depth physiological, economic, social, and lifestyle basis.
• Diagnosis and analysis — the nurse considers the physical symptoms and patient behavior and forms a diagnosis or analysis of cues to determine the current nursing priority.
• Outcomes and planning — the nurse uses their expertise to set realistic goals for the patient's recovery and monitors those objectives closely.
• Implementation — the nurse implements the plan of care and documents the patient's progress.
• Evaluation — the nurse analyzes the effectiveness of the plan of care, studies the patient response, and alters the plan of care to achieve the best patient outcomes. (ANA Standards of Critical Nursing Practice, 1988).

Tanner's Clinical Judgment Model

1. Noticing — What clinical data does the nurse recognize as important and/or significant?
2. Interpreting — What is the meaning or clinical significance of relevant clinical data that was noticed?
3. Responding — How will the nurse respond with a nursing priority and plan of care based on the clinical data that was noticed and interpreted?
4. Reflecting — After responding, what is the evaluation, reflecting on clinical data noticed by the nurse? (Tanner, 2006)

Revised Clinical Judgment Model

Based on Tanner's Clinical Judgment Model and Neilsen, Stragnell, and Jester's article Guide for reflection using the clinical judgment model, instructors from the UW-Madison School of Nursing have developed a revised model that also addresses issues of diversity, equity, social justice, and health equity into the equation. This added element of Personalizing asks the nursing to consider the emotions, reactions, beliefs, and biases they bring to the care of a patient and develop a plan for self-care that manages these feelings to ensure fair and equitable care of the patient.

Citations

• Alfaro-LeFevre, R. (2017). Critical thinking, clinical reasoning, and clinical judgment: A practical approach. (6th ed.). St. Louise, MO: Elsevier-Saudners.
• Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
• Manetti, W. (2019). Sound clinical judgment in nursing: A concept analysis: MANETTI. Nursing Forum, 54)1, 102-110.
• Nielsen, A., Stragnell, S., & Jester, P. (2007) Guide for reflection using the clinical judgment model. The Journal of Nursing Education, 46(11), 513-516.
• Rischer, K. (2021). Faculty guide to develop clinical judgment: Transforming nursing education through the use of clinical reasoning case studies.
• Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. The Journal of Nursing Education, 45(6), 204-211).