Christy Bowen; Lindsay Draper; Heather Moore

Learning Objectives

By the end of this section, you will be able to:

Identify the purpose for development of the Clinical Judgment Measurement Model (CJMM)
Explain how to apply the Clinical Judgment Measurement Model (CJMM) to the nursing practice

Historically, nursing was often viewed as a “task-oriented” career, meaning that nurses were to take orders from physicians without question and carry out nursing tasks. These tasks were usually simple, such as bed linen changes, helping patients use the toilet, and providing hygiene care. However, the profession of nursing has evolved into a more complex, autonomous career over the past several decades. Nurses now use clinical judgment, which is the thought process that allows nurses to arrive at a conclusion, based on objective and subjective information about a patient, to achieve positive patient outcomes. Many times, nurses are the care providers tasked with making clinical decisions that will significantly affect the lives of their patients. In recent years, nursing education has also evolved to better train nurses to critically think and use clinical judgment in practice. To achieve this, the Clinical Judgment Measurement Model (CJMM) was developed. This model allows nurse educators to teach, assess, and measure the development of clinical judgment skills of nursing students. It assists nursing students to connect knowledge learned in the classroom to provide exceptional clinical care in practice. This model is the new foundation for nursing critical thinking and skill development and is discussed in more detail throughout this chapter.

Purpose for Development of the CJMM

Before development of the CJMM, there was not a good way to measure the clinical judgment and decision-making skills of nursing students. Developing these skills was a priority focus of most nursing programs, but there was no tangible way to measure it to ensure it was being taught effectively. This was the basis for the development of the CJMM. Researchers at the National Council of State Boards of Nursing (NCSBN) used nursing literature and research studies, in combination with data analysis and input from nursing students, to develop the CJMM. This model is used not only as a teaching tool within nursing school curricula, it is also used as a guiding framework for the development of new types of questions on the National Council Licensure Examination (NCLEX) to assess nursing student’s clinical judgment and critical thinking skills. By using the CJMM, nurse educators can be more confident that they are preparing nursing students to enter practice with a high level of critical thinking and the ability to make sound clinical judgments when caring for their patients. It also provides students with a structured approach for decision-making, improves students’ decision-making, and supports quality and safety.

Link to Learning

You can learn more about the new NCLEX examination that incorporates concepts from the CJMM and get prepared for test day.

Comparing Different Nursing Process Models

Before development of the CJMM, the nursing process was “ADPIE,” which stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation. This nursing framework was developed in the 1950s and continues to be used in some capacity today, though most nursing schools have replaced it with the CJMM, which further expands the nursing process into more measurable components. A description of each of the steps of the original nursing framework is given in Table 43.1.

Steps	Description
Assessment	Data can also be collected from electronic health records. Data collection (both subjective and objective) Data are collected from the patient directly and/or from family and caregivers in addition to physical assessment of the patient performed by the nurse.
Diagnosis	Formulation of a nursing diagnosis The International North American Nursing Diagnosis Association maintains a list of nursing diagnoses that can be used to describe a patient’s situation. Note that nursing diagnoses are separate from medical diagnoses; for example, a patient with a medical diagnosis of heart failure might have a nursing diagnosis of “decreased cardiac output.”
Planning	Goals and patient outcomes are developed. Goals should be patient specific and mutually agreed upon with the nurse and patient. Goals should be “SMART,” meaning they are specific, measurable, attainable, realistic, and timely. Nursing care plans are developed to ensure that care provided will help achieve patient goals.
Implementation	Actions by the nurse Carrying out the nursing interventions planned in the previous step (e.g., administering medications)
Evaluation	Reassess patient after interventions are provided. Determine whether patient goals have been met and if and how care plan needs to be revised.

Table 43.1 Steps of the Nursing Process

Using the nursing process has many benefits for nurses, patients, and other members of the healthcare team. The benefits of using the nursing process include:

decreases omissions and duplications
encourages collaborative management of a patient’s healthcare problems
identifies a patient’s goals and strategies to attain them
improves patient safety
improves patient satisfaction
increases the likelihood of achieving positive patient outcomes
promotes quality patient care
provides a guide for all staff involved to provide consistent and responsive care saves time, energy, and frustration by creating a care plan or path to follow

Link to Learning

Learn more about the CJMM to explore new ways of testing clinical judgment in nursing as part of the NCLEX.

Application of the CJMM to Nursing Practice

There are several layers to the CJMM framework. Layer 0, at the top, is the broadest layer and the layers get more specific as the reach the bottom at layer 4. As nurses move through layers 2 through 4, they are working through a cognitive process that helps them make clinical decisions for patients, using clinical judgment to do so (as represented by the broad layers 0 and 1 at the top of the model). The more specific layers (2–4) are discussed in more detail in the following sections.

Form, Refine, and Evaluate Hypotheses

Layer 2 of the CJMM is composed of three different parts: form hypotheses, refine hypotheses, and evaluation. The nurse uses specific patient assessment findings (“cues”) to develop hypotheses, or educated guesses, about the patient’s condition. The nurse uses the cues in combination with their foundational clinical knowledge to determine potential explanations for the patient’s situation. As more cues are assessed and more information about the patient is obtained, the nurse can refine their initial hypothesis and determine its accuracy. As the nurse moves through the steps in layers 3 and 4 to make clinical decisions, they are also checking in with the parts of this layer to continuously re-evaluate the plan of care. As you will read in the next section, each of the cognitive skills in layer 3 corresponds to a component of layer 2. As the nurse assesses and cares for a patient, they can determine whether their actions have satisfied the goals of care. If the goals are not satisfied, the nurse can move again through the steps in layers 3 and 4 to revise the care plan and make different clinical decisions that, hopefully, will assist in better meeting the patient's needs.

Application of Cognitive Skills

Layer 3 of the CJMM is composed of six steps that involve a repetitious process that improves with time and nursing experience. Eventually, these steps become second nature to a more experienced nurse, but they serve as a framework for nursing students and early-career nurses to use as a more deliberate guide for making clinical decisions. These six cognitive skill steps (also known as clinical judgment functions) are described in more detail in Table 43.2.

Cognitive Skill	Description
Recognize cues	Assessment data are collected. These can be subjective from the patient or family or objective from physical assessment performed by the nurse. Data can also be collected from the electronic health record. Nurse uses these assessment data to look for cues that may be indicative of what is going on with the patient. Nurse tries to determine what information is relevant, what is the most important, and if there is anything that is of immediate concern.
Analyze cues	Nurse takes the assessment data collected from the previous step and considers how they relates to the patient’s history and current situation. Nurse considers whether the cues collected in the previous step are consistent with the patient’s current condition, if any of the cues are immediately concerning, and if there are additional data that need to be collected. Nurse attempts to link recognized cues to the patient’s clinical presentation and establish probable patient needs, concerns, or problems.
Prioritize hypotheses	Nurse examines all possibilities for the patient’s situation based on collected cues. Nurse determines which possibilities are most likely, which are most serious, and which are the highest priority to treat first. Priorities of care are established on the basis of the patient’s current health problems and cues assessed in the first two steps.
Generate solutions	Using hypotheses for the patient’s condition from the previous step, nurse plans specific actions to achieve goals and outcomes. Actions can be classified as “indicated,” “contraindicated,” or “nonessential” to help determine priority actions. During this step, the nurse should identify outcomes that are expected with each nursing action and plan care that addresses patient’s current needs.
Take action	Nurse performs interventions, which may be further assessment, monitoring, teaching, or actual interventions, depending on the patient’s needs. Actions are based on nursing knowledge, priorities of care, and planned outcomes to achieve optimal health outcomes for the patient.
Evaluate outcomes	Nurse reviews patient response to actions and interventions. Nurse compares observed outcomes with expected outcomes to determine if the plan of care needs to be revised.

Table 43.2 Cognitive Skills in the CJMM

Expected Responses and Behaviors

For each cognitive skill, there are specific responses and behaviors the nursing student is expected to exhibit. When expected responses are performed by the student, it indicates that the cognitive skill has been adequately demonstrated, thus the student is using clinical judgment effectively. Expected responses and behaviors by the student that would indicate they can successfully recognize cues include recognizing assessment data pertinent to the patient’s condition, identifying subtle changes in the patient’s condition, and using knowledge and experience to thoroughly assess the patient.

To analyze cues, it is expected that the student can recognize abnormal assessment findings, anticipate patient needs, identify potential complications that may arise, and begin to prioritize patient problems. When prioritizing hypotheses, the student nurse should be able to organize data and findings based on patterns and trends and prioritize the patient’s goals and needs. During the generate solutions (planning) step, the student nurse is expected to collaborate with the interprofessional care team to establish goals of care, prioritize nursing interventions based on the patient’s needs, and continuously modify the plan of care based on patient condition changes. When the student begins to the take action step, it is expected that they will accurately perform nursing interventions based on previously established patient priorities and needs, document care appropriately, and provide education to the patient and family. When evaluating outcomes, expected behaviors include reassessing the patient’s condition to determine whether goals and outcomes have been met, evaluating how effective nursing interventions were, and modifying patient goals and priorities as needed.

Consideration of Factors

While using clinical judgment to make practice decisions, it is important to do so within the context of environmental and individual factors. These factors are specific to each patient and help the nurse make informed, personalized decisions.

Environmental Factors

Environmental factors are things within the external environment that may affect the clinical decision-making process. These factors include:

culture (e.g., diet, religion, language, literacy)
individual medical information, including medical history, laboratory and diagnostic test results, intake and output, medications, and current treatments
patient demographics
resources (e.g., supplies, staffing, open beds)
setting (e.g., hospital, long-term care, community health center)
situational factors (e.g., safety considerations, available equipment, surroundings)
time pressure related to emergent orders and changes in patient condition

Cultural Context

Cultural Context within the CJMM

Cultural factors must be considered as part of the clinical judgment process. Without this context, it may be difficult to ascertain the cause of the patient’s condition. For example, in some cultures, a vegetarian diet is common. In the context of this factor, the nurse must consider that a lack of protein and vitamin B12 may be the cause of certain medical issues within this population. Although considering cultural factors is important, it is even more important not to generalize information about cultures, because this can border on perpetuating stereotypes. There is a difference between generalizing information about all members of a population versus asking questions about the patient’s culture to get specific information that can help the nurse make informed clinical decisions.

Individual Factors

Individual factors that must be considered during the clinical judgment process are more related to the nurse than the patient. These factors include:

cognitive load of the nurse (e.g., demands, job stress, problem solving skills, memory)
nurse characteristics, including attitudes, prior experiences, amount of nursing experience
nurse specialty, knowledge, and skills

Real RN Stories

Floating to Different Units: Considering the Nurse’s Experience

Nurse: Gabby, BSN
Clinical setting: Medical-surgical unit
Years in practice: 3
Facility location: Small community hospital in rural Georgia

After clocking in for my shift, I was notified by the charge nurse that I would be floating to a different unit for the night. She told me I would need to go to the labor and delivery unit to help out because there were several patients being admitted who would be delivering babies that night. I had only ever worked on a medical-surgical unit, so I expressed that I was concerned and uncomfortable taking care of this patient population. The charge nurse shrugged her shoulders and informed me I was floating to the unit anyway.

Once I got to the unit, the labor and delivery charge nurse told me I would be taking care of a patient who had just delivered a baby 2 hours ago. I again expressed my discomfort, because I had never taken care of postpartum mothers or babies. The charge nurse seemed surprised by this and stated, “I was told they were sending down a nurse with obstetrics experience. Let me make a call real quick.”

When the charge nurse came back from making her phone call, she informed me that there had been a mistake and a different nurse with obstetrics experience was supposed to float to the unit, not me. I breathed a huge sigh of relief and headed back to my home unit, thankful that I advocated for myself and the patients.

43.1 Clinical Judgment Measure Model