Clinical judgment: Clinical decision making

Clinical judgment is the result of a complex, iterative process that nurses use to make decisions about patient care. Effective clinical judgment allows nurses to successfully navigate patient needs within various clinical scenarios, and is essential for providing safe, quality care and improving patient outcomes.

Now, there are two primary models that use the concept of clinical judgment: Tanner’s Clinical Judgment Model, or CJM, and the Clinical Judgment Measurement Model, or CJMM.

Tanner’s Clinical Judgment Model provides a framework to guide novice and expert nurses in developing sound clinical judgments. The model includes four main components including noticing, interpreting, responding, and reflecting.

First, noticing involves observing and grasping the current situation. These observations can include information such as the patient’s presenting signs and symptoms, medical history, and current laboratory or diagnostic test results. Noticing is shaped by a nurse’s previous practice experiences in a specific environment, familiarity with certain patient populations, as well as the nurse’s understanding of a patient’s usual patterns of behavior.

Next is interpreting, where the nurse analyzes and understands the significance of the information noticed in the previous step. Once the nurse interprets the information, the next step is responding, where the nurse plans care and intervenes to meet patient needs. The final step is reflecting, which occurs once interventions have been implemented. This is when the nurse evaluates the outcomes of their actions, based on the patient’s response, determines whether the interventions were effective or ineffective, and adjusts them as needed. In this step, the nurse also learns from the experience and further develops their clinical judgment so it can be applied to future scenarios.

Okay, switching gears, the Clinical Judgment Measurement Model is designed to be a valid method of measuring clinical judgment and decision making on certain nursing licensure exams. While this framework was created for examination purposes, it can also be used to explain the process of arriving at clinical judgments within clinical contexts encountered by nurses in various practice settings.

According to the CJMM, several layers make up clinical judgment for nurses. First, layer 0 is a broad layer demonstrating that patient needs are met with clinical decisions. Next are layers 1 through 3, which involve cognitive operations within clinical judgment. Layer 1 represents the overarching process of clinical judgment, and layer 2 illustrates the process of forming, refining, and evaluating hypotheses about a patient’s needs. Then, layer 3 breaks down the previous components into six tangible tasks necessary to make clinical decisions.

Lastly, layer 4 provides contextual considerations for clinical decision making, including environmental factors, like short staffing, and individual factors, like the nurse’s level of experience. Keep in mind, this process is iterative, meaning it may restart several times until the desired patient outcomes are achieved.

Now, let’s focus on the six steps in layer 3. First, recognize cues is when the nurse identifies relevant patient information, such as the patient’s presenting signs and symptoms, medical history, and current laboratory or diagnostic test results.

Next, analyze cues, is when the nurse interprets information from the previous step by linking the cues to the patient’s presentation. For instance, the nurse identifies how pathophysiological processes relate to the patient’s clinical presentation, anticipates certain complications that are likely to occur, and seeks additional information to explain the significance of the cues.

After that, prioritize hypotheses is when the most likely explanations behind the patient’s presentation are ranked based on relevance and urgency.

The nurse then generates solutions where outcomes or goals are developed to meet patient needs in a timely manner. After that, take action is when interventions are chosen and implemented based on priority needs.