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)
- Understand how to apply the CJMM to the nursing practice
Researchers at the National Council of State Boards of Nursing (NCSBN) developed the NCSBN Clinical Judgment Measurement Model (CJMM) as a framework for the valid measurement of clinical judgment and decision-making within the context of a standardized, high-stakes examination. Although clinical judgment and decision-making have been important elements in most prelicensure education programs for many years, significant research and development were required to isolate and measure these traits with psychometric rigor. This model is used as a teaching tool within nursing school curriculums and as a guiding framework for the development of new types of questions on the national board exam (NCLEX) to examine the clinical judgment and critical thinking skills of nursing students. By using the CJMM, nurse educators can be confident that they are preparing nursing students to enter practice with high-level critical thinking skills and the ability to make sound clinical judgments when caring for their patients.
Link to Learning
You can learn more about the NCLEX examination that incorporates concepts from the CJMM and get prepared for test day.
The Clinical Judgment Measurement Model
Though the traditional ADPIE nursing process has existed for a long time and still provides great value to nursing, many nursing schools are now utilizing the CJMM more, as it further expands on the nursing process and allows it to be broken down into more measurable components.
Link to Learning
The National Council of State Boards of Nursing created the Clinical Judgment Measurement Model (CJMM) to explore new ways of testing clinical judgment in nursing as part of the National Council Licensure Examination (NCLEX). The diagram at this site shows the layers of the model.
Application of the CJMM to Nursing Practice
There are several layers to the CJMM framework. Layer 0 at the top is the broadest layer, encompassing all the clinical decisions that a nurse makes to address a patient’s needs—essentially the entire nursing process. However, as you move down the model, you can see that this process is broken into more specific steps that nurses can use to make clinical decisions and address patient needs. As nurses move through layers 2 through 4, they are working through a specific 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 through 4) are discussed in more detail in the following sections.
Form, Refine, and Evaluate Hypotheses
Layer 2 is composed of three different parts: form hypotheses, refine hypotheses, and evaluation. The nurse uses specific patient assessment findings (“cues”), to develop hypotheses 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 the nurse assesses more cues and obtains more information about the patient, 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 layer 2 to continuously reevaluate 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 met,” the nurse can move again through the steps in layers 3 and 4 to revise the care plan and make different clinical decisions that will hopefully assist in better meeting the patient's needs.
For example, a nurse is caring for a patient who presents with a cough and fever. The nurse assesses the patient and determines that the patient also has a runny nose, shortness of breath, and dyspnea on exertion. The nurse hypothesizes that the patient has a respiratory virus and administers an influenza and COVID-19 test per the provider’s order. The COVID-19 test comes back positive, confirming the nurse’s hypothesis, so the nurse notifies the provider and initiates appropriate measures as ordered, including supplemental oxygen and intravenous (IV) fluids. The nurse reevaluates the patient several hours later and determines that the patient’s symptoms have improved. This is an example of how a nurse could move through the steps of the CJMM to make clinical decisions to address the patient’s current 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 4.1 and throughout the rest of the chapter.
| Cognitive Skill | Description |
|---|---|
| Recognize cues |
|
| Analyze cues |
|
| Prioritize hypotheses |
|
| Generate solutions |
|
| Take action |
|
| Evaluate outcomes |
|
The CJMM is more advanced than the traditional ADPIE nursing process for several reasons. First, the focus of the CJMM is critical thinking and clinical judgment. Using this model, the nurse must continuously reassess, adapt, and refine their clinical judgment to make appropriate decisions as new information becomes available or the patient’s condition changes. Additionally, the CJMM is more patient-centered; it tailors nursing care by incorporating contextual factors such as the patient’s unique preferences, values, and culture, as well as social determinants of health. It is important to recognize that in a time-sensitive situation, clinical judgment might lean toward quick decision-making, whereas critical thinking may advocate for a more deliberate analysis. Navigating conflicts involves balancing the urgency of the situation with the need for a thoughtful approach, ensuring that both critical thinking and clinical judgment contribute to optimal patient care.
Expected Responses and Behaviors
For each cognitive skill, there are specific responses and behaviors that 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 and the student is using clinical judgment effectively.
- Expected responses and behaviors by the student that would indicate they are able to successfully recognize cues include recognizing assessment data that are pertinent to the patient’s condition, identifying subtle changes in the patient’s condition, and using knowledge and experience to thoroughly assess the patient.
- For analyzing 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 changes to the patient’s condition.
- When the student begins to take action, 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
It is important to use clinical judgment to make practice decisions within the context of environmental and individual factors, which form layer 4 of the CJMM. These factors help the nurse make informed, personalized decisions. The contextual factors surrounding a nurse’s ability to provide care, such as time pressure, prior experience, and task complexity, must be taken into account.
Environmental
External environmental factors are physical and social factors within the external environment that may affect the clinical decision-making process. These include the following:
- setting (e.g., hospital, long-term care, community health center)
- situational factors, such as safety considerations, available equipment, and surroundings
- patient demographics
- resources, such as supplies, staffing, and open beds
- individual medical information, including medical history, lab and diagnostic test results, intake/output, medications, and current treatments
- time pressure related to emergent orders and changes in patient condition
- culture (e.g., diet, religion, language, literacy)
- payment for health-care services
In addition to external environmental factors, there are also many internal environmental factors to consider. These include physiological, psychological, sociocultural, and spiritual factors that influence the patient from within.
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 commonplace. 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, as this can perpetuate stereotypes. There is a difference between generalizing information about all members of a population and asking questions about the patient’s culture to get specific information that can help the nurse make informed clinical decisions.
Individual
Individual factors that need to be considered during the clinical judgment process are factors related to the nurse. These factors include the following:
- nurse specialty, knowledge, and skills
- nurse characteristics, including attitudes, prior experiences, and amount of nursing experience
- cognitive load of the nurse (e.g., demands, job stress, problem-solving skills, memory)