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Psychiatric-Mental Health Nursing

28.2 Measurement of Clinical Judgment

Psychiatric-Mental Health Nursing28.2 Measurement of Clinical Judgment

Learning Objectives

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

  • Define how the National Council of State Boards of Nursing (NCSBN) utilizes the Clinical Judgment Measurement Model (CJMM)
  • Discuss assessment of nursing knowledge by the NCLEX
  • Apply clinical judgment to client care

Nursing judgment is a learned skill. The ability to think critically develops more fully over time in nursing practice. Basic understanding of the process is evaluated pre-licensure during the nurse’s academic preparation and on the licensure examination for nursing graduates.

Every two years, the National Council of State Boards of Nursing (NCSBN) investigates nursing education and aspects of the nursing workforce via survey in the United States. These surveys provide information on the type of practice required and the availability of working nurses. This information is utilized for curriculum development in schools of nursing and workforce planning in health-care settings as well as in the development of questions for NCLEX. This section addresses the measurement of nursing judgment, specifically on the licensure examination, and in nursing practice.

National Council of State Boards of Nursing (NCSBN) and the Clinical Judgment Measurement Model

American states and territories establish what constitutes legal nursing practice through their own Nurse Practice Acts to safeguard recipients of nursing care and to protect nurses within the profession. These acts specify requirements of nursing education programs, requirements to be licensed as a nurse, scopes of practice at the levels of professional, practical, assistant, and advanced nursing, and disciplinary action for violations in practice. These are regulatory functions of state boards of nursing. The National Council of State Boards of Nursing (NCSBN) is the agency that coordinates these regulatory functions in the United States.

Boards of nursing also have research functions, as described in the preceding paragraph regarding surveys. Evidence-based research informs regulatory criteria and contributes to the overall nursing and health-care database. In 2023, this research action resulted in changes to the National Council Licensure Examination for Registered Nurses (NCLEX-RN).

Presentation of the Clinical Judgment Measurement Model (CJMM)

Utilizing research data, the NCSBN identified a need to measure nursing judgment and knowledge of clinical skills more realistically. Because the NCLEX-RN measures graduate nurses’ understanding of safe practice at the entry level, this was a critical public health and professional competency initiative. The Clinical Judgment Measurement Model (CJMM) was developed for this purpose. It is a decision-making model for answering questions on the NCLEX-RN, though it is valuable in nursing practice as well.

Nurses may be familiar with other decision-making models. One is a simple visual flowchart or algorithm called a decision tree, which graphs predictions or consequences of actions (Figure 28.4).

Decision tree asking: Take action? Answers to choose from: Is support available? (leads to Proceed now or Proceed later) or Support not available? (leads to No action).
Figure 28.4 A decision tree is one type of decision-making model that can be used by nurses in practice. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Another model is the scientific PICOT format that nurses may have used in academic research courses. A clinical inquiry is proposed by the researcher and formatted to streamline a literature search process. Figure 28.5 shows an example.

PICOT Model of Clinical Inquiry Topics of inquiry include: Population, Intervention, Comparison, Outcome, Timeframe, with an example inquiry and answers to the PICOT questions.
Figure 28.5 This format is a model of inquiry. P=Population or Problem being studied, I=Intervention/nursing action, C=Comparison to other or existing or no action, O=expected Outcome, and T=Time frame to conduct the study. (modification of work from Fundamentals of Nursing. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Decision-making models serve as frameworks for analysis of possible solutions to identified problems. Decision-making models assist with clarifying collected data toward a conclusion for best action. The CJMM presents a decision-making process specifically designed for nursing practice.

Levels of Clinical Decision-Making/Reasoning

The CJMM has layers, which represent levels of decision-making. The nurse applies critical-thinking skills to discern what clients need at any given time.

Layers 0 and 1 represent a continual loop between client needs, application of nursing judgment to clinical decisions, and back to more assessment of client needs. Expert nursing practice was defined by Benner’s classic work (1982) as the length of practice at five years or more wherein the client’s needs are identified and addressed by clinical decisions using clinical judgment. Notice the word satisfied is shown at Level 1, meaning goals of treatment were met. The expert nurse goes on to the next client need from here, or supports the client’s recovery, repeating Layers 0 and 1 through termination of the therapeutic relationship. The process is grasped intuitively by the nurse at this level of practice and nursing interventions are efficiently focused (Ozdemir, 2019).

Layers 2, 3, and 4 depict the actions nurses can take, and the concepts to consider, if the client’s needs are not satisfied (meaning goals are unmet or partially met). These words are shown in the middle of the graphic at Level 2, showing that evaluation leads back to more review of the data. Layers 2, 3, and 4 are guidelines that can result in outcomes of care, which will again be evaluated for effectiveness. The entire process is learned over time as nurses increase in practice proficiency.

Layer 4 includes the environment, which is everything surrounding the nurse-client relationship that will influence outcomes. The term individual refers to nurses themselves and to nurses’ abilities (Table 28.1). All of these considerations factor in to determine if the client’s need can be met in this environment by this individual. Keep in mind that the CJMM was developed to evaluate cognitive skill of the test-taker. Therefore, on Layer 4 under Individual Factor Examples, “Candidate Characteristics” refers to the nursing graduate taking the NCLEX-RN. In licensed practice, this would be “Nurse Characteristics.”

Type of Factor Factor Examples
Environmental (everything surrounding the client) Environment Everything surrounding the nurse-client interaction: physical setting/location, like temperature of the space, privacy, presence of others, lighting, noise, odors; emotional atmosphere, like accepting, supportive, nurturing versus judgmental, hostile, frightening
Client observation Assessment data, expressed symptoms
Resources Equipment, supplies, levels, and numbers of staff and support services
Medical records Electronic access, history, recent events
Consequences and risks Potential for violence, danger, infection, adverse reactions, medical errors, falls, potential outcomes
Time pressure Rapid developments, workload, schedules
Task complexity Components of care, steps in a procedure or process, knowledge/assistance required
Cultural considerations Age, belief systems, traditions, client's social structure
Individual (the nurse) Knowledge What is understood about the client's situation
Skills Technical and cognitive proficiency as result of teaching and training
Specialty Clinical certification, practice in defined nursing fields
Candidate (nurse) characteristics Patience, flexibility, motivation, confidence versus anxiety, rigidity, reluctance, self-doubt
Prior experience Applicable to current demands
Level of experience Entry-level, competent, expert
Table 28.1 Layer 4 of the CJMM

Assessment of Nursing Knowledge by the NCLEX-RN

As stated, the NCLEX-RN changed in 2023 due to research evidence of the need for nursing graduates to show increased understanding of safe practice at the entry level. Focus and format of the questions on the licensure examination changed to meet this goal. Time frame for completion of the NCLEX-RN examination is five hours after the candidate opens the test on the computer. The examination presents the test-taker with items (questions) that pose problem-solving scenarios, in short form as specific questions, or in longer form as client need categories. Candidates can expect items to address categories as depicted in Figure 28.6.

NCLEX breakdown of question categories chart detailing the types of questions asked as well as the approximate percentage of those questions by category, ranging from 9-20 questions per category.
Figure 28.6 This graph shows the approximate breakdown in categories of questions on the NCLEX, but distributions may vary slightly based on individual examinations. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

To guide the candidate’s study, meaning of the categories depicted left-to-right on the graph are as follows:

  • Management of care means the nurse observes scope of practice guidelines, incorporates all available supports, delegates and directs others, and conserves resources.
  • Pharmacological and parenteral therapies mean the nurse safely administers or supervises safe administration of prescribed medications, fluids, and blood products by all routes and teaches and monitors indication, intended effect, side effects, and adverse reactions.
  • Physiologic adaptation means the nurse manages and promotes clients’ adjustment to emergency, corrective or supportive care, interventions, and treatments.
  • Reduction of risk potential means the nurse monitors for complications of clients’ diagnoses and educates and intervenes to mitigate potential harms and adverse outcomes to care and treatment.
  • Safety and infection control means the nurse recognizes and mitigates harm and risks, observes practice standards, monitors client acuity, and educates others.
  • Health promotion and maintenance means the nurse brings preventative care and wellness care at all stages of human development, detects potential problems, and conducts health screening.
  • Psychosocial integrity means the nurse promotes clients’ adaptation and stress management, teaches others, integrates nursing interventions, advocates for emotional, social, and spiritual wellness, and delivers psychiatric nursing care in therapeutic settings.
  • Basic care and comfort mean the nurse provides and directs physical care for basic needs, such as nutrition, hydration, comfort, elimination, activity, and rest.

The essence of nursing practice is the identification of client needs, which are then addressed through the nursing process. By successful completion of the NCLEX-RN, nursing graduates show their competence at the entry level of practice. Nursing graduates must think about how all these categories apply in psychiatric-mental health (PMH) nursing.

Computerized Interactive Questions

The NCLEX-RN items measure clinical judgment by case study and stand-alone questions. Case studies present multiple questions about a realistic nursing care scenario. Stand-alone items ask for application of the six elements in Layer 3 of the CJMM, which are steps of the nursing process, and, as discussed, depict the actions the nurse can take. Answers may be entered by “click to specify” or “click to highlight” chosen responses. Test item formats include bow-tie, drag and drop, drop-down, extended multiple response, and matrix. Visualizing questions on a split screen is another new feature of the exam.

  • Bow tie: Move provided answers to provided categories.
  • Drag and drop: Move provided answers to the correct target.
  • Drop down: Select an option from text, chart, or table.
  • Extended multiple response: Select all applicable responses; partial credit is awarded for items with more than one key.
  • Matrix: Select from a table of options in columns or rows.

Presented in the next section will be examples of these question types used in an evolving case study.

Available Resources

Knowledge base and examination preparation together are essential for NCLEX success.

Schools of nursing provide preparation for the NCLEX throughout the nursing program, many utilizing a software package. Near graduation, programs offer more specific preparation in the forms of exit exams, capstone projects, clinical preceptorship/field placements, or wrap-up components of the school’s software product. In addition, final semester students frequently present a project that is designed to bring together multiple concepts of nursing practice.

There are numerous NCLEX preparation offerings. Nursing graduates may personally decide how to customize the process. What is important to the test-taker? Graduates should consider their own learning style. Printed materials, online formats, mobile applications, videos on demand, practice questions, recorded mini-lectures, question libraries, and real-time study groups, coaches, and tutors are all available.

Graduates may want to consider whether the study resource contains access to customized study help and access to user reviews. Cost is another factor, whether purchase or subscription. The testing programs selected by the graduate’s school of nursing can serve as a guide for NCLEX prep or prompt investigation into what other schools use. Important to consider is practice with simulated adaptive NCLEX-style test items. The graduate’s selection of preparation packages should include those that provide a focus on Next Gen type questions.

Application of Clinical Judgment to Client Care

Nursing graduates can think of the NCLEX-RN as a safety test. The test evaluates candidates’ ability to decide how to proceed in client care situations, not memorization of answers to standard questions. Expect scenarios posing complex decisions that require cultural competence and use of available resources. NCLEX-RN seeks to present situations that occur in real health-care settings. There is an increased focus on client acuity and nursing management of change in condition. The goal is improvement in care that avoids medical errors by emphasizing clinical judgment.

Specific to PMH nursing, the licensure exam will address nursing process in care of clients experiencing disorders covered in this textbook, recognition of signs and symptoms, risk factors, aspects of recovery, legal and ethical concerns, and nurses’ self-care. Psychopharmacology, therapies, theories, client behaviors, and clients’ experience will also be topics for test items.

Collaboration for Client Care Approaches

As presented in this chapter, evidence-based practice is a combination of science, nursing expertise, and client preferences. Quality and Safety Education for Nurses (QSEN) concepts call for multiple health-care professionals to practice in partnership with the client and family. Interprofessional collaboration is endorsed by multiple professional organizations (University of North Carolina, n.d.). NCLEX-RN test items will present problem-solving scenarios to evaluate skills in these domains.

Table 28.2 provides examples of nursing actions to meet the QSEN Competencies as related to PMH nursing.

QSEN Competency: PMH Nurses can: PMH Nurses can: PMH Nurses can: PMH Nurses can: PMH Nurses can:
Person-Centered Care Form a therapeutic alliance with the client.
Obtain and interpret assessment data (recognize cues) through therapeutic communication.
Utilize active listening with a family member reluctant to have a loved one hospitalized. Document the client’s expression of anxiety. Determine client’s preference prior to a procedure. Role model for others’ consideration for client’s values and beliefs.
Teamwork and Collaboration Participate as client advocate during interdisciplinary team meetings. Share decision-making with peers and colleagues who are participating in the client’s care. Consult with, or offer referral to, other professionals when clients express or demonstrate select needs, i.e., spiritual support. Inform clients that their personal information is kept confidential. Inform clients that their information is shared with the care team only, especially when safety is a concern.
Evidence-Based Practice Refer to organizational policy and procedure to understand rationale for care. Seek membership in councils or research groups in the workplace. Keep informed of current pharmacological data. Distinguish opinion from research evidence. Keep informed of current practice, especially regarding most restrictive interventions, i.e., seclusion and restraint.
Quality Improvement (QI) Use available data to monitor outcomes of care. Ensure that care is safe and effective. Use QI processes within the organization to plan practice change. Identify unit-based opportunities to improve safety. Role model advocacy for the client’s experience.
Safety Reduce risk through effective nursing care and delegation. Observe established practice guidelines. Teach clients strategies for personal safety. Monitor client situations for increased risk, i.e., rising anxiety or increased social withdrawal. Keep a safe environment.
Information Use informatics and technology to inform clinical decision-making. Protect the client’s confidentiality. Share client information with appropriate team members when safety is a concern. Use stored data for analysis of client care. Teach and assist utilization of telehealth as indicated.
Table 28.2 QSEN Competencies for PMH Nursing (Dolansky & Moore, 2013; QSEN Institute, n.d.)

Developing Clinical Judgment

According to the American Association of Colleges of Nursing (AACN):

As one of the key attributes of professional nursing, clinical judgment refers to the process by which nurses make decisions based on nursing knowledge (evidence, theories, ways/patterns of knowing), other disciplinary knowledge, critical thinking, and clinical reasoning (n.d., para 1).

Clinical judgment, involving critical thinking and clinical reasoning as applied to nursing care scenarios, is an essential skill for the nurse to provide quality care. Clinical judgment develops over time in clinical practice through exposure to various client care situations with application of these thought processes to nursing practice.

Prior to licensure, schools reinforce learning of clinical judgment using the Clinical Judgment Measurement Model. NCLEX test items are intended to reflect the atmosphere of the clinical setting where actions, including errors, have consequences. Safety and effectiveness of all nursing care depends upon accurate application of the nursing process.

Nurses can develop clinical judgment through both independent and collaborative actions, such as:

  • Ask coworkers for tips and suggestions; observe and assist others.
  • Receive feedback professionally and request review of work.
  • Review the medical record and learn to make connections to care, for example, medications to lab values, vital signs, or client experience.
  • Become familiar with screening tools and assessment resource material.
  • Ask questions about the rationale for procedures.
  • Review unit-based data for fall rates, infections, or readmissions.
  • Read research abstracts, follow up on those of interest.

Collaborative action:

  • Engage with clients, families, and other professionals in care planning.
  • Seek supportive relationships with educators and mentors in the workplace.
  • Discuss research evidence with other nurses.
  • Participate in unit-based or facility-wide activities for education, community involvement, or employee morale.
  • Accompany clients off-unit to imaging or diagnostic procedures, to support the client and interact with other professionals in those departments.
  • As appropriate, be present when consultants, therapists, and medical providers interact with clients to support the client and learn how services interface.
  • Request a “shadow shift,” especially in areas connected to your unit, for example, emergency department and medical-surgical floor, intensive care unit and step-down unit.

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