CAPS

Clinical Judgment Measurement Model

Next Generation NCLEX NEWS

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WINTER 2019

The Next Generation NCLEX® News is a quarterly publication that provides the latest information about the research being done to assess potential changes to the NCLEX Examinations.

In this issue, you will find information related to clinical judgment. Clinical judgment is defined as the

observed outcome of critical thinking and decision making. It is an iterative process that uses nursing

knowledge to observe and assess presenting situations, identify a prioritized client concern and

generate the best possible evidence-based solutions in order to deliver safe client care.

NCSBN research identified a list of contextual factors that play a role in the quality of nursing clinical

judgment (Dickison et al, 2016). These factors may be divided into conditions that are internal (education,

experience, knowledge, communication, consequences/risk, emotions/perceptions, professional

orientation) or external (task complexity, time pressures, distractions, interruptions, professional autonomy)

to the nurse.

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Recognizing that it was necessary to ascertain whether clinical judgment is more than

just possessing nursing knowledge, NCSBN conducted a pilot study in 2016 (Muntean

et al. 2016 AERA presentation). Results from this study found that while knowledge is

essential, it is not enough to substantiate the clinical judgment essential to safe nursing

practice. The study also indicated that the average ability of a nurse to demonstrate the

different steps in the clinical judgment process (cue recognition, hypothesis generation,

hypothesis evaluation, taking actions and evaluating outcomes) is progressive.

Thus, a nurse’s ability to recognize cues, develop hypotheses

and take appropriate actions does not guarantee the ability

to evaluate the outcomes of the action taken. Ultimately,

no single element of clinical judgment adequately predicts

a nurse’s clinical judgment ability; it is the combination

of all the elements that add validity and reliability to the

measurement of a nurse’s clinical judgment ability. In short,

having content knowledge does not always translate to

having clinical judgment skills.

The NCSBN Clinical Judgment Measurement Model (CJMM)

represents a fundamental shift from the current dichotomous

measurement models in which something is either right or

wrong. When context is removed and items are extremely

sterile, a very precise and stable measurement can be

obtained. But, the context in which we make decisions

matters. Consequences, time constraints and risks cause

someone to make decisions a certain way. The CJMM

(see pg. 3) can be broken down into four levels. Imagine

that a nurse walks into a client room, cues exist that must

be first be recognized and then analyzed in order to care

for the client properly.

The nurse (1) forms hypotheses, (2) prioritizes them,

(3) generates solutions and then (4) takes actions. Research

thus far has indicated that these actions can be measured. Layer 4 in the CJMM is one

that has not been introduced in any psychometric models before now – the context.

The question is whether you can put context around items in a way that you actually

make it more real.

NCSBN continues to develop item prototypes, collect data and do research on

measuring clinical judgment and measuring the layers of the CJMM.

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“Because we know that nurse

client care and nurse errors

can be improved by enhancing

clinical judgment skills in novice

nurses, it is imperative that we

find a way to assess the degree

to which NCLEX candidates

possess clinical judgment. It is a

critical component of the overall

goal of ascertaining whether a

nursing candidate is minimally

competent. This is a public

protection issue.”

— Philip Dickison

WINTER 2019 · 2

Next Generation NCLEX NEWS

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References

Dickison, P., Haerling, K. & Lasater, K. (in press). Integrating the National Council State Boards of Nursing-Clinical Judgment Model (NCSBN-CJM) into Nursing Educational Frameworks. Manuscript submitted for publication. Dickison, P., Lou, X., Kim, D., Woo, A., Muntean, W., & Bergstrom, B. (2016). Assessing higher-order cognitive constructs by using an information-processing framework. Journal of Applied Testing Technology, Vol 17(1), 1-19.

Muntean, W. J. (2015). Evaluating clinical judgment in licensure tests: Applications of decision theory. Paper presented in the annual meeting of the American Educational Research Association in Chicago, IL.

The NCSBN Clinical Judgment Measurement Model

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Copyright ©2019 NCSBN. All Rights Reserved.

The NCSBN Clincial Judgment Measurement Model

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The Layers of the Clinical Judgment Measurement Model

1. Recognize Cues – Identify relevant and important information from different sources (e.g., medical history, vital signs).

2. Analyze Cues – Organizing and linking the recognized cues to the client’s clinical presentation.

Recognize Cues Identify relevant and important information from different sources (e.g., medical history, vital signs).

• What information is relevant/irrelevant?

• What information is most important?

• What is of immediate concern?

Do not connect cues with hypotheses just yet.

Analyze Cues Organizing and linking the recognized cues to the client’s clinical presentation.

• What client conditions are consistent with the cues?

• Are there cues that support or contraindicate a particular condition?

• Why is a particular cue or subset of cues of concern?

• What other information would help establish the significance of a cue or set of cues?

Consider multiple things that could be happening. Narrowing things down comes at the next step.

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3. Prioritize Hypotheses – Evaluating and ranking hypotheses according to priority (urgency, likelihood, risk, difficulty, time, etc.).

4. Generate Solutions – Identifying expected outcomes and using hypotheses to define a set of interventions for the expected outcomes.

Evaluating and ranking hypotheses according to priority (urgency, likelihood, risk, difficulty, time, etc.).

• Which explanations are most/least likely?

• Which possible explanations are the most serious?

Item development should focus on ranking the potential issues and should use phrases such as "most likely."

Prioritize Hypotheses

Generate Solutions Identifying expected outcomes and using hypotheses to define a set of interventions for the expected outcomes.

• What are the desirable outcomes?

• What interventions can achieve those outcomes?

• What should be avoided?

Focus on goals and multiple potential interventions—not just the best one—that connect to those goals. Potential solutions could include collecting additional information.

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5. Take Action – Implementing the solution(s) that addresses the highest priorities.

6. Evaluate Outcomes – Comparing observed outcomes against expected outcomes.

Implementing the solution(s) that addresses the highest priorities.

• Which intervention or combination of interventions is most appropriate?

• How should the intervention(s) be accomplished (performed, requested, administered, communicated, taught, documented, etc.)?

For “how” questions, ensure that specific elements from the scenario are what determines approach. Avoid memorized or “textbook” procedures. The item stem and/or the responses should include action verbs.

Take Action

Evaluate outcomes Comparing observed outcomes against expected outcomes.

• What signs point to improving/declining/ unchanged status?

• Were the interventions effective?

• Would other interventions have been more effective?

Item development should focus on the efficacy of the intervention(s) from the previous items.

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NGN Talks In order to provide information regarding aspects of the Next Generation NCLEX (NGN) project such as the topic of the Clinical Judgment Measurement Model (CJMM), the NCSBN Examinations Department has begun recording a series of videos entitled “NGN Talks.”

NGN Talks are available for public viewing. The videos include 5-7 minutes of informational details about various aspects of the NGN project. NGN Talks are presented by the Examinations Department’s staff and include topics such as an introduction to NGN, item development, test validity, and many other aspects of the NGN research project. The first NGN Talk provides an introduction to the NGN project, and is now posted on the NCSBN website.

Access NGN Talks

Next Generation NCLEX® News is published by National Council of State Boards of Nursing (NCSBN)

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Phone: 312.525.3600 International Calls: +1.312.525.3600

Website: www.ncsbn.org

NCSBN provides education, service and research through collaborative leadership to promote evidence-based regulatory excellence for patient safety and public protection.

Copyright ©2019 NCSBN. All Rights Reserved.

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