NGN Case Study Workbook

Chapter 3 · Clinical Judgment and the Nursing Process

Clinical judgment may be defined as the observed outcome of critical thinking and decision making, in which the nurse applies nursing knowledge to observe and assess presenting situations, identify a prioritized client concern and generate the best possible evidence-based solutions. To measure this construct on the licensure examination, the National Council of State Boards of Nursing developed the Clinical Judgment Measurement Model, a layered framework that links observable decisions to the underlying cognitive processes from which they arise.

Within this framework, the central layer comprises six cognitive operations. Recognizing cues refers to the identification of relevant and important information from the client record and environment. Analyzing cues involves organizing and connecting those findings to the client's clinical presentation. Prioritizing hypotheses requires the nurse to evaluate and rank competing explanations according to urgency, likelihood and risk. These operations correspond broadly to the assessment and diagnostic phases of the traditional nursing process, although they are described in more explicitly cognitive terms.

The remaining operations address intervention and appraisal. Generating solutions entails identifying expected outcomes and selecting interventions that are likely to achieve them while excluding those that are ineffective or harmful. Taking action refers to implementing the chosen interventions in a safe and appropriate sequence within the nurse's scope of practice. Evaluating outcomes requires comparison of observed client responses with expected outcomes in order to determine whether the plan was effective, whether the client's condition has changed and whether further intervention is required.

The model further recognizes that clinical judgment is shaped by environmental factors, such as time pressure, available resources and the medical record, and by individual factors, including the nurse's knowledge, skills and prior experience. Next Generation examination items operationalize these concepts through unfolding case studies in which each item targets a single cognitive operation. Because item formats such as matrix, drop-down and highlight questions may award partial credit, candidates benefit from understanding both the underlying model and the scoring rules applied to each format.