Clinical Judgment and HESI: Learning and Assessment for Practice Readiness

According to the National Council of State Boards of Nursing (NCSBN®), clinical judgment (CJ) is the "doing" part of critical thinking and clinical decision making. This is important to note because a lot of research points towards the need for more "doing" during the learning process in nursing education.

The main goal of the NCLEX® is to help identify whether nurses entering practice are safe and practice ready. As NCSBN does extensive research, let's consider what they are finding in the healthcare industry.

Mini-History Lesson

In the late 90s, research indicated that 100,000 people were dying each year because of mistakes in healthcare. This birthed the Institute of Medicine's five core competencies, which led to the Robert Wood Johnson Foundation launching one of the most important academic initiatives of the 21st century known as QSEN (Quality and Safety Education for Nurses).

In one recent study, it's noted that approximately 250,000 people per year are now dying in the American healthcare system because of mistakes. In another study, using a practice assessment tool called the Performance Based Development System (PBDS) assessment, only 23% of new graduates were identified as practice ready.

So, What?

Given NCSBN's concern with safety and practice readiness, it is beginning to impress upon nurse educators, the importance of assessing graduates with a tool which focuses even more on clinical judgement. Ultimately, NCSBN wants to ensure graduates possess the ability for high-level processing.

In the near future, we can count on the NCLEX becoming more difficult in that it will assess a student for processing and not content. Students will need to illustrate competence on more of the higher-level questions than in the past. These are questions at and above the application and analysis level of Bloom's taxonomy.

HESI is not Optional

One crucial concern with developing clinical judgment skills is that each individual is unique. No two nursing students are going to ever be at the exact same place when it comes to developing and strengthening their CJ muscles. Therefore, nurse educators need to empower their students to find their own gaps and focus their study/growth/practice on their personal weaknesses.

First, how do students know how they are doing in developing their own personal clinical judgment? Better yet, do students even know what CJ is? We need to provide them with data on how they are doing that they can trust and manage.

For example, what if you were caring for a newly-diagnosed client with type-II diabetes mellitus (DM). You say to the client, "We need to get your blood glucose levels under control. Here is some good reading, here is your insulin/medications and syringes, here are the signs/symptoms of hyper/hypoglycemia." Then you send them on his/her way. What is missing? The client knows a lot about DM, but how will he/she know their daily blood glucose levels (in many cases multiple times a day)?

A valid and reliable glucometer is needed. Then, over time, the client will need a Hemoglobin A1c that is valid and reliable. What if he/she didn't have these assessments?

HESI is that powerful, well-developed glucometer and Hgb A1c for your student. It is carefully researched and constantly assessed for continuous quality, not just periodic updates.

HESI for Formative/Daily Assessment

The patient with diabetes needs daily feedback on his/her blood glucose levels (many require a daily glucometer reading). With this information, the person with DM can make on-the-go adjustments to help optimize the management of the disease. The patient can't wait for the provider to give them assessment data and a plan.

Students need this type of autonomous freedom as well. Clinical judgment requires continuous practice and focus on the "doing" part of nursing. HESI Case Studies and Patient Reviews are the continuous glucometer readings for the student.

When students complete a case study, they receive instant feedback on where they are related to clinical judgment. HESI case studies are extensively researched and validated to ensure they point the student directly towards the "doing" part of nursing, while giving immediate feedback on their own personal strengths and weaknesses.

Because these case studies are high quality and evidence based, they allow students to learn while doing. Taking this learning to the next level, they are also getting feedback from the software. Another way students can receive feedback on their CJ skills is to have them work together as they complete a case study. When they work together they are observing each other's clinical judgment skills and learning different ways of processing.

After a pair completes a HESI Case Study or Patient Review they should then create a handoff report (SBAR is a great one to use for handoff). Then, they find another pair and give each other the report. After the report is given, the recipient gives feedback.

Another strategy that promotes clinical judgment is to have the students retake a case study in post conference after a day of caring for a client in a clinical setting or after completing a simulation. Try to find a case that relates to the client they cared for that day in clinical/lab. When completing the case, the student is in a deep level of reflection on their own personal practice (to include performance in the area of CJ), and hence really deepens the learning that occurred during that patient care experience.

One final formative strategy to promote the development of clinical judgment is to have the students work together during lecture to develop a practice NCLEX-style question related to the case study. This question needs to help them focus on clinical judgement, not a low-level definition or memorization nugget. Help them see where several concepts intersect in patient care as you mentor them in the development of this practice test question. Once they've developed their question, they swap questions with another student (or pair) and give each other feedback. After peer feedback is considered, the students then upload their creation into an online discussion forum. The instructor reviews the questions and randomly picks one to modify and add to the next exam.

HESI for Summative/Progression Assessment

The best way to assess a patient with DM for long-term management of their blood glucose levels is the Hgb A1c. In a similar fashion, if you want a valid and reliable assessment of a student's development in clinical judgment, you should use a proven standardized assessment for two reasons.

First, the standardized assessment is vital to the students knowing exactly where they are weak and strong. When a student takes a standardized exam (e.g. HESI Pharmacology) they are going to be measured against thousands of students across the nation. The most powerful part of these assessments is that the students will get a full report on many different competency taxonomies including: nursing process, NCLEX, and much more.

The power in the student having personal assessment data like this, is that in future learning experiences, he/she can use that data to grow their clinical judgment skills. For instance, if the student takes a final in pharmacology that is a standardized exam and the results indicate their weakest area of the nursing process is planning, he/she can use that information in the next semester clinical.

The following semester they can carry a note card in their pocket (lecture, lab, clinical) with the planning part of the nursing process written on it with bullets. Anytime the student encounters a case study or an actual patient, he/she can pull out the card and explain/highlight planning to another person. This is focused, individualized remediation for that specific student.

Second, the standardized assessment is powerful because it is instant curricular feedback for the instructor on how the students are doing in clinical judgment. However, when they administer a specialty exam, educators receive instant, useful data that can help them make necessary course adjustments in the short-term (lesson plan) and the long term (curricular plan).

Student-Centered Learning

As nurses, we know that the patient with DM will do better if they are fully informed, take control, and are a completely integrated member of the healthcare team. Education is no different. Nursing students need to be able to constantly receive feedback on their trajectory. Just as we would not ask the patient with DM to wait three weeks to get feedback on how management of his/her disease is going, we can't ask the students to wait.

Using the HESI Case Studies and Patient Reviews on a daily/weekly basis gives the learner full control over their own learning. Students will leave each case study experience with a valid assessment of their own clinical judgment abilities and know exactly what part of the process needs to be addressed.

Tim Bristol,


For more tips and resources from Tim Bristol, click here.
To learn more about the next generation of HESI, click here.

Contact your Elsevier Education Solutions Consultant to discuss how HESI can help you meet your goals and improve outcomes