Med-Surg · chapter 4 · Clinical Judgment in the Nursing Process
Clinical Judgment Measurement Model Overview
The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 3 practice questions with the reasoning.
Key points
CJMM purpose
Researchers at the National Council of State Boards of Nursing (NCSBN) developed the NCSBN Clinical Judgment Measurement Model (CJMM) as a framework for the valid measurement of clinical judgment and decision-making within the context of a standardized, high-stakes examination.
CJMM educational use
This model is used as a teaching tool within nursing school curriculums and as a guiding framework for the development of new types of questions on the national board exam (NCLEX) to examine the clinical judgment and critical thinking skills of nursing students.
CJMM and ADPIE
Though the traditional ADPIE nursing process has existed for a long time and still provides great value to nursing, many nursing schools are now utilizing the CJMM more, as it further expands on the nursing process and allows it to be broken down into more measurable components.
Layer 0 scope
Layer 0 at the top is the broadest layer, encompassing all the clinical decisions that a nurse makes to address a patient’s needs—essentially the entire nursing process.
Layers 2 through 4
As nurses move through layers 2 through 4, they are working through a specific cognitive process that helps them make clinical decisions for patients, using clinical judgment to do so (as represented by the broad layers 0 and 1 at the top of the model).
Cues and hypotheses
The nurse uses specific patient assessment findings (“cues”), to develop hypotheses about the patient’s condition. The nurse uses the cues in combination with their foundational clinical knowledge to determine potential explanations for the patient’s situation.
Refining hypotheses
As the nurse assesses more cues and obtains more information about the patient, the nurse can refine their initial hypothesis and determine its accuracy.
Reevaluating care plan
As the nurse moves through the steps in layers 3 and 4 to make clinical decisions, they are also checking in with the parts of layer 2 to continuously reevaluate the plan of care.
When goals are not met
If the goals are “not met,” the nurse can move again through the steps in layers 3 and 4 to revise the care plan and make different clinical decisions that will hopefully assist in better meeting the patient's needs.
Layer 3 process
Layer 3 of the CJMM is composed of six steps that involve a repetitious process that improves with time and nursing experience.
Ongoing clinical judgment
Using this model, the nurse must continuously reassess, adapt, and refine their clinical judgment to make appropriate decisions as new information becomes available or the patient’s condition changes.
Patient-centered CJMM
Additionally, the CJMM is more patient-centered; it tailors nursing care by incorporating contextual factors such as the patient’s unique preferences, values, and culture, as well as social determinants of health.
Layer 4 factors
It is important to use clinical judgment to make practice decisions within the context of environmental and individual factors, which form layer 4 of the CJMM. These factors help the nurse make informed, personalized decisions.
Cultural generalization
Although considering cultural factors is important, it is even more important not to generalize information about cultures, as this can perpetuate stereotypes.
Terms to know
- NCSBN Clinical Judgment Measurement Model (CJMM)
- Researchers at the National Council of State Boards of Nursing (NCSBN) developed the NCSBN Clinical Judgment Measurement Model (CJMM) as a framework for the valid measurement of clinical judgment and decision-making within the context of a standardized, high-stakes examination.
- cues
- The nurse uses specific patient assessment findings (“cues”), to develop hypotheses about the patient’s condition.
- clinical judgment functions
- These six cognitive skill steps (also known as clinical judgment functions) are described in more detail in Table 4.1 and throughout the rest of the chapter.
- External environmental factors
- External environmental factors are physical and social factors within the external environment that may affect the clinical decision-making process.
- Individual factors
- Individual factors that need to be considered during the clinical judgment process are factors related to the nurse.
Practice questions
Stuck on select-all-that-apply? How to take them one option at a time.
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Every question here, with the answer
Several hours after a patient with a positive COVID-19 test received ordered supplemental oxygen and IV fluids, the nurse reassesses the patient. Symptoms have improved, which was the expected outcome. Which entry best documents evaluation of outcomes using the CJMM?
- Cough, fever, runny nose, shortness of breath, and dyspnea on exertion identified as relevant assessment cues.
- Positive COVID-19 test supports the respiratory-virus hypothesis; provider notified and ordered care provided.
- Symptoms improved following ordered interventions; observed response is consistent with the expected outcome.
- Supplemental oxygen and IV fluids administered as ordered; patient reassessed several hours after treatment.
Answer: Symptoms improved following ordered interventions; observed response is consistent with the expected outcome.
The correct entry compares the patient's observed response with the expected outcome, demonstrating evaluation rather than simply recording completed tasks. The other entries document hypothesis confirmation, interventions and reassessment activity, or assessment cues without showing whether the expected outcome was achieved.
A patient with cough and fever has tested positive for COVID-19, and the provider has ordered supplemental oxygen and IV fluids. A nursing student has established priorities and a plan of care. Which activities belong to carrying out and documenting the CJMM's take-action step? Select all that apply.
- Compare the patient's response to interventions with the expected outcomes.
- Rank possible explanations for the patient's cough and fever by likelihood and seriousness.
- Administer the ordered supplemental oxygen and IV fluids according to the established priorities.
- Provide education to the patient and family.
- Document the care provided to the patient.
Answer: Administer the ordered supplemental oxygen and IV fluids according to the established priorities., Provide education to the patient and family., Document the care provided to the patient.
Taking action includes performing interventions based on established priorities, documenting care appropriately, and educating the patient and family. Ranking possible explanations belongs to prioritizing hypotheses, while comparing observed and expected responses belongs to evaluating outcomes; both are useful but demonstrate different CJMM skills.
At the start of an assessment, a nurse is completing the dietary history for a patient from a culture in which vegetarian diets are common. The patient has not yet described their own diet. Which approach best supports individualized clinical judgment?
- Ask about the patient's own dietary practices and document the specific information obtained.
- Enter a vegetarian diet based on the patient's cultural background and ask the patient to confirm it during later teaching.
- Use the culture's typical dietary pattern as a provisional cue unless the patient volunteers a different practice.
- Document the cultural background but exclude dietary practices from the assessment to avoid stereotyping.
Answer: Ask about the patient's own dietary practices and document the specific information obtained.
Asking the patient provides specific information that can inform clinical decisions without treating a cultural pattern as an individual fact. Entering an assumed diet or relying on a typical pattern risks stereotyping, while excluding dietary practices discards potentially relevant context.
Where every quote comes from
Section 4.2 Clinical Judgment Measurement Model Overview of Medical-Surgical Nursing by Christy Bowen, Bridget Carey, Jessica Palozie, Maren Reinholdt, OpenStax, 2024. Read the whole section free at openstax.org.
The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.