Readying Ourselves
As we know, change is coming. The National Council of State Boards of Nursing (NCSBN®) has confirmed that the earliest that the Next Generation NCLEX® (NGN) would be implemented is 2023. This is an update from the original information shared in Charlotte, NC in September 2018 that indicated that implementation could begin in 2022 or 2023.
One of the biggest questions on the minds of nursing educators is, “How do we get ready for NGN, when we don’t quite know what to expect?” At first, this can be an overwhelming question. However, when we focus on what we do know — that clinical judgment is key — it becomes more apparent. We need to continue developing thought processes that help students develop a salience of the situations in which they find themselves. Following a model or theory is a sound, reliable way in which to develop thought processes.
Depending on your particular curriculum, you may subscribe to one of several different methods of “thinking like a nurse” — most commonly, nurse educators report using ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation), AAPIE (Assessment, Analysis, Planning, Implementation, Evaluation), or Tanner’s Model (Noticing, Interpreting, Responding, Reflecting) as their means for doing so.
When we line the NCSBN Clinical Judgment Model (CJM) up with the components of ADPIE, AAPIE, and Tanner, it becomes easier to see that you may already be on the right path to teaching and reinforcing clinical judgment. For example, do you use AAPIE as your approach to patient care? If so, when you are teaching students how to perform assessment, you are, in fact, teaching them to recognize cues (CJM), and you are teaching them noticing (Tanner) skills. When you are helping them understand how to plan and implement interventions (AAPIE), you are teaching them to generate solutions and take action (CJM), which is the essence of how to respond (Tanner).
Capitalizing on what you are already doing by using interchangeable and relatable language of the models/theories can help us as faculty use language that is pertinent to NGN.
Keep in mind that the CJM was designed to “explore new ways of testing clinical judgment in the nursing profession as part of the licensure examination” (NCSBN, 2019b). Dickison, Haerling, & Lasater (2019) developed a hypothetical action model to help faculty implement the clinical judgment model. The action model “incorporate[s] specific concepts of the CJM … required in order to close the gap between what is measured on the exam and what is taught in clinical nursing education” (NCSBN, 2019b).
Nursing faculty can help to close the gap by “beginning to incorporate the CJM model into their curriculum immediately” (NCSBN, 2019a), in didactic, laboratory, and clinical settings. Select methods by which this can be accomplished are discussed in the following section.
Readying Students
While the Clinical Judgment Model (CJM) itself appears complex, the action model shows how cognitive operations, like recognizing cues, are applied. Using the CJM, the recognition of cues involves assessment of elements that includes environment, client observation, medical records, resources, time pressure, consequences and risk, task complexity, and cultural consideration. Analyzing cues requires the nurse to apply knowledge to the assessed cues and then prioritize hypotheses in order to determine how to intervene first.
Remember, failure to rescue is still a presiding problem in nursing due to errors of omission, failure to recognize changing patient conditions, and failures in clinical decision making (Mushta, Rush, & Anderson, 2018). Helping nursing students to prioritize care, as well as to generate solutions, are essential parts of addressing the issues we face in regard to failure to rescue. Teaching with this model combines textbook knowledge (e.g. the underlying pathophysiological process and nursing process) to the present clinical scenario. After generating solutions, use of the CJM moves the student nurse to take action which requires nursing experience and a progression of clinical judgment.
You may think that a beginning or foundations (fundamentals) level nursing student does not have experience with which to take action. However, within each level of nursing education, a student has gained a skill set and expanded upon their thought processes that are commensurate with that level of education. They have also gained life experience that adds to the context through which they make judgments. This idea is integrated into the CJM via individual factors which includes knowledge, specialty, skills, candidate characteristics, prior experience, and level of experience.
Within the CJM, action is then followed by the evaluation of outcomes, moving back to the assessment of cues.
Want to learn more from Cherie Rebar and Nicole Heimgartner? Don’t miss their blog Getting Students Ready for Next Generation NCLEX.
References
Dickison, P., Haerling, K. & Lasater, K. (2019). Integrating the National Council State Boards of Nursing-Clinical Judgment Model (NCSBN-CJM) into Nursing Educational Frameworks. Journal of Nursing Education, 58(2), 72-8.
Mushta, J., Rush, K., & Anderson, E. (2018). Failure to rescue as a nurse-sensitive indicator. Nursing Forum, 53(1), 84-92.
NCSBN. (2019a). FAQs for educators. Retrieved from https://www.ncsbn.org/11447.htm
NCSBN. (2019b). Next Generation NCLEX News: The Clinical Judgment Model and action model. Retrieved from https://www.ncsbn.org/NGN_Spring19_Eng_04_Final.pdf