For an experienced nurse, clinical judgment is an automatic process that takes place multiple times a day using a combination of assessment, knowledge, intentional thought, collaboration, and even intuition. This complicated skill is what defines an exceptional nurse. Check out the NSCBN Clinical Judgment Model to see how complicated the process can be.
Creative tips for teaching clinical judgment
The implications of the clinical judgment process have profound effects on clients when novice nurses and students fail to rescue the client from a change in condition. Because the novice nurse does not have the experience to make decisions automatically, the skill must be taught. First, we need to teach the steps of the process, then weave in critical thinking and while providing opportunities for practice. Because clinical judgment is a process and skill, frequent application and practice must be intentional. We should use every opportunity for practice. Here are some learning strategies you may find helpful in each of these areas:
Students may miss the opportunity to identify the exact point when clinical decisions must be made. They need our assistance to analyze these situations and to practice critical thinking.
Activity #1: Instruct students to diagram or write up the details of a decision that was made for their client. Apply the steps of the nursing process to a specific situation. For example, when the client’s temperature became elevated, or the client asked for pain medication, or a critical lab result was received. How did the nurse make the decision in each of these situations? Students need to discuss the situation with the nurse to collect the pertinent data and discover and evaluate the critical thinking that was used to make the decision. This decision diagram could be submitted for a grade instead of a written care plan or could be discussed in post-conference.
Activity #2: Assign two clients who are receiving IV fluids to each student. The student should research the medical record and talk to the nurse to answer these questions:
- What is the rationale for the type and rate of the fluids?
- Was the type or rate changed at any point and why?
- Is the outcome for the fluids effective at this time?
- What data would demonstrate an effective outcome for the fluids?
A similar assignment could be made using two clients who are receiving diuretics or oxygen or physical therapy.
Clinical judgment and decision-making should always be a standard discussion topic during post conference.
During the initial demonstration of a skill, we know that students will be focused on the correct steps, not the variations in care. Therefore, following mastery of a new skill in the lab, we need to discuss when to alter the steps or implementation of the skill.
Activity #1: Set up practice stations to create opportunities for clinical judgment. For urinary catheterization, this could include a female client (manikin) who could not bend the knees up or a male client with prostate enlargement. At the end of practice time, have a debrief session to discuss how decisions were made and evaluate results.
Activity #2: Show pictures or a short video about implementation of a skill in a difficult situation. Have the group brainstorm ways to solve the problem. A good place to start is with insulin injection. Students could be presented with a variety of body types to determine how to adjust the angle of the needle.
In upper-level classes, use most of your class time for discussion of complex nursing actions that require clinical judgment, prioritization, and evaluation of outcomes. Incorporate the use of the NCSBN Clinical Judgment Model and discuss various pieces of the model throughout the semester.
Activity #1: Present a piece of data that demonstrates a change in condition for a client. Have student pairs determine what the nurse needs to do and explain their rationale. During a class on Parkinson’s Disease, use these situations:
- The client becomes confused.
- The client is incontinent.
- The client has new swallowing problems.
- The client falls.
The same situations could then be discussed for a client with a stroke and the clinical judgment process could be compared for the two conditions.
Activity #2: Create a round-robin application activity. Give each student group some limited data related to the topic of the day including a change in client condition. Ask each group to diagram the nursing process related to that specific change. After five minutes, pass the paper to another group who continues work on the new situation. After ten minutes, move the papers again to another group. For example, one group could have a client with cirrhosis who starts vomiting blood. Another group could have a client with cirrhosis who has jaundice and pruritis. Another group could have a client with cirrhosis and ascites.
Activity #3: When discussing complications of a condition, it is important to ask students how they would assess for the presence of the complication and what their initial response would be. For instance, when discussing chemotherapy, ask students how the nurse would handle diarrhea, or weakness, or anorexia, or a metal taste in the mouth.
Always have debrief time with the entire group after application activities. Here are some sample questions to ask:
- How confident did you feel about your decision?
- What other data would have helped you make the decision?
- How did prioritization influence your decision?
- What data would demonstrate an effective outcome for the client?
This is the perfect opportunity to practice clinical judgment and decision-making as well as prioritization. If the prepared scenario doesn’t include a change in client condition, pause for five to 10 minutes during the simulation to present a change and verbally discuss the possible causes, related assessment data, best decision to be made, rationale for the decision and data that demonstrates a positive outcome.
Within any simulation scenario, the client could have a planned change in vital signs, or the presence of a new complication, or altered lab work. To prevent students from feeling overwhelmed, only change one piece of data. If they don’t identify the change or respond inappropriately, be sure to bring it up during debrief as an important discovery moment.
After a simulation, consider having students brainstorm ways to include clinical judgment in the scenario. Then use their ideas during the next implementation of that scenario. Be sure to give credit to the group.
As a standard practice, always include at least one question about clinical judgment during simulation debrief. Use the four debrief questions from the Class section above.
Overall, the ultimate goal for every student is to develop effective clinical judgment skills. Try at least one or two ideas each semester. Ask the students to evaluate the activity and make suggestions for improved implementation in the future. This helps them become more invested in the learning process and provides valuable feedback on the benefits of these exercises. Finally, can you share one of your ideas? What strategies have worked for you in teaching clinical judgment and decision-making?