Healthcare Foundations PrepU ch. 14 Clinical Judgement
American Nurses Association The American Nurses Association (ANA) produces and maintains Nursing: Scope and Standards of Practice. This resource is considered the authority on scope of practice. The other listed organizations all inform nursing education and nursing practice in different ways, but none delineate the scope of practice.
A community health nurse has recommended a specific, medicated wound-care product to a client with a chronic venous ulcer. A colleague has asserted that the nurse has exceeded the scope of practice. The two nurses should consult resources from what organization to resolve this dispute about the scope of practice?
"It is definitely a clear model, but it does not really capture all of the complexities and the human element of nursing." The information-processing model is attractive by virtue of its simplicity and linear nature. However, there is no significant drive to apply this model to nursing practice, because nursing is psychosocially complex and cannot be reduced to a simple equation of input and output. For this reason, it has never been predominant in nursing, even in past decades. It has not been proven to achieve better client outcomes in the literature.
A group of student nurses has been encouraged by their instructors to be intentional and deliberate about applying clinical decision-making models to their practice. A student tells a colleague, "The model that makes the most sense to me is the information-processing model, because it seems the most straightforward." How should the colleague best respond to this student?
Interpret the data to determine meaning In Tanner's model, the phase of noticing is followed by interpreting and then responding. Reflection occurs later in the sequence of actions. Eliciting client input is appropriate, but is not an explicit portion of Tanner's model.
A home health nurse has entered a client's home and rapidly noticed some significant characteristics of the client's home setting and the client's appearance. When applying Tanner's model of clinical judgment, what should the nurse do next?
client-centered care Adjusting a client's care in response to the client's preferences or abilities is indicative of client-centered care. Quality improvement is focused more broadly on systems and processes. Empathic care and accountability and adaptability are not QSEN competencies.
A hospital client who requires assistance with hygiene has expressed a preference for receiving a bed bath after lunch rather than in the morning. The nurse has consequently changed the nursing care plan. The nurse's action reflects which QSEN competency?
Tanner's clinical judgment model Unlike the other listed models, the Lasater Clinical Judgment Rubric is explicitly designed to measure students' achievement of Tanner's model.
A junior nursing student has learned that clinical and simulation performance will be measured according to the Lasater Clinical Judgment Rubric. This student is in a curriculum that subscribes to what model of clinical judgment?
The nurse integrates experience and reflections into new forms of practice. Transformation encompasses meaningful change that results from integrating new experiences with reflections. This may result in practice improvements, increased awareness of ethics, or influence on others, but it is the convergence of experience and reflection that most clearly indicates personal transformation.
A novice nurse has been growing in skill, largely as a result of experiential learning in the clinical setting. Within the model of experiential learning, what outcome would most clearly indicate that the nurse has achieved the stage of transformation?
Tanner's clinical judgment model Although the nurse's actions are not inconsistent with any of the listed models, the integration of the specific steps of noticing, interpreting, responding, and reflecting demonstrates Tanner's clinical judgment model
A nurse has entered a client's home and noticed the client's disheveled state and several fall risks in the home. The nurse has interpreted these data as indications of a need for increased home support for the client and responded by arranging for care. The nurse reflected on the client's response to this suggestion, as well as reflected on the course of this interaction after the fact. The nurse has most clearly exemplified what model?
Tanner's clinical judgment model Although the nurse's actions are not inconsistent with any of the listed models, the integration of the specific steps of noticing, interpreting, responding, and reflecting demonstrates Tanner's clinical judgment model.
A nurse has entered a client's home and noticed the client's disheveled state and several fall risks in the home. The nurse has interpreted these data as indications of a need for increased home support for the client and responded by arranging for care. The nurse reflected on the client's response to this suggestion, as well as reflected on the course of this interaction after the fact. The nurse has most clearly exemplified what model?
American Nurses Association While each of the listed organizations provides resources and information of different types, this dispute is directly related to scope of practice, which is delineated by the American Nurses Association's Nursing: Scope and Standards of Practice.
A nurse has recommended a regimen of over-the-counter medications for a client who has seasonal allergies. A colleague contends that the nurse has exceeded the scope of nursing practice by recommending medications to a client. To resolve this difference of opinion, the nurses should consult resources from what organization?
Reflect on any biases that the nurse may have Within cognitive continuum theory (CCT), intuition requires a careful examination of any potential biases the nurse may have. This theory does not prioritize cognitive learning over affective or kinesthetic learning. Mentoring can be beneficial but is not a particular focus of CCT. Similarly, gaining clinical experience is helpful but is not an explicit focus of CCT.
A nurse is applying cognitive continuum theory (CCT) to the care that is provided on a geriatric care unit. To strengthen the intuitive aspect of this theory, the nurse will perform what action?
The speed and complexity of the situation overwhelmed the nurse's cognitive load. Overstimulation in this case overwhelmed the nurse's cognitive load, leading to a failure to recognize, process, and act upon information. This is unrelated to the differences between inductive and deductive reasoning. The nurse's situational awareness decreased once overwhelmed, not increased. It is unlikely that this nurse's response was related to a lack of understanding that clinical judgment and clinical reasoning are important.
A nurse is distraught that she failed to intervene promptly in a situation where a client's status declined sharply. The client was becoming agitated and aggressive. The nurse states, "There was just too much going on, all at once, and I basically froze and then panicked." What interpretation of this event is most accurate?
teamwork and collaboration Although this action is consistent with all the QSEN competencies, delegation is a practical example of the competency of collaboration and teamwork in the clinical setting.
A nurse is navigating a busy morning on a hospital unit and is struggling to finish the necessary tasks in the time available. In response, the nurse has assigned morning hygiene tasks for two clients to an unlicensed assistive personnel (UAP). What QSEN competency is this nurse exemplifying?
determining whether an advanced wound care technique is within the scope of practice The American Nurses Association (ANA) performs several important roles related to nursing practice. However, it is unique in producing the Nursing: Scope and Standards of Practice. The ANA does not administer the NCLEX nor does it participate directly in labor matters related to collective bargaining.
A nursing student has drawn on resources from many organizations while learning and practicing as a student nurse. For which action will resources from the American Nurses Association be appropriate?
National League for Nursing The competencies identified by the National League for Nursing include human flourishing, nursing judgment, professional identity, and spirit of inquiry. None of the other listed organizations share this particular taxonomy of competencies.
A nursing student is excited to begin the first semester of the program and has learned that the competencies embedded in the program include human flourishing, nursing judgment, professional identity, and spirit of inquiry. What is the source of these competencies?
by engaging in frequent and thoughtful reflection In experiential learning, there is a progression from experiences to reflection to transformation. Without reflection, new learning cannot be gleaned from experiences and used to inform future actions. Simply increasing the pace or quantity of learning is not sufficient, nor can a mentor's guidance replace this vital step.
A nursing student is moving through a curriculum that emphasizes the value of experiential learning. The nursing student is consciously linking previous experiences with new and transformative practices. How will the nursing student link experiences with transformative behaviors?
The Lasater Clinical Judgment Rubric The Lasater Clinical Judgment Rubric was expressly created to allow the evaluation of Tanner's model. Each of the other tools listed are congruent with Tanner's model, but none exist for the specific purpose of evaluating students' use of the model.
A nursing student is progressing successfully through the nursing curriculum, which integrates Tanner's model of clinical judgment. The student's use of this model can be most directly evaluated and quantified using what tool?
novice Reliance on rote procedures and unawareness of contextual factors are the hallmarks of a novice. Advanced beginners have started to move away from this concrete thinking and performing. Benner's model does not include categories of precompetent or orientee.
A nursing student is providing care on a subacute step-down unit. The nursing student has received feedback that they are excessively tied to the rigid, stepwise performance of clinical tasks and fail to notice and accommodate the many contextual factors in client interactions. The nursing student is at what stage of Benner's humanistic-intuitive model of clinical judgment?
National Council of State Boards of Nursing (NCSBN) The six steps listed constitute the NCSBN's Clinical Judgment Measurement Model (CJMM). Although it is not contrary to the values or guidance of the other listed entities, this model is specifically proposed by the NCSBN.
When identifying and responding to a client's anxiety, the nurse has moved through the process of recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes. The nurse's actions reflect a model proposed by the:
The nursing student relies on memorizing the steps involved in nursing tasks. The nursing student demonstrates concrete thinking when faced with complex clinical situations. Thinking that is concrete, rote, and linear is associated with novices. Asking questions, reviewing information, or becoming involved in conflicts does not necessarily indicate novice status; each is often necessary, even for more experienced nurses.
A senior nursing student is completing a preceptorship at a busy inpatient unit. What aspect(s) of the nursing student's care suggests that the nursing student is practicing at a novice level within Benner's humanistic-intuitive model of nursing development? Select all that apply.
"Reflection is important for processing and learning from clinical experiences." "Reflection is an intentional process that aids your growth in knowledge and skill." "Without reflection, it is hard to transform your experiences into professional growth." Reflection is an intentional process that is key to deriving meaning and growth from experiences. It must begin at the start of a nurse's learning journey; it doesn't begin once "expert" skill has been attained. Forms of reflection are often required in nursing curriculums but the essential benefit of reflection is not simply to demonstrate learning to an instructor.
A student has begun the first year of the BSN curriculum and is skeptical about the benefits of reflection. What benefit(s) of reflection should a classmate describe to this student? Select all that apply.
Perform intentional personal reflection In experiential learning, the cyclic nature of learning is driven by concrete experience, termed prehension, followed by reflective observation, which leads to the formation of abstract concepts that are then tested in new situations through experimentation, the integration of which is termed transformation. Reflection is the key to deriving growth from experiences, more so than delaying feedback, repeating experiences, or teaching others.
A student nurse has been benefiting from the experiential learning in the simulation laboratory. In this setting, the student has gained a wide variety of experiences and has the goal of transforming nursing behavior. To link experiences with transformation, what will the student do?
The student nurse thought systematically and reflectively before deciding what to do Although there are many definitions of what constitutes critical thinking, there is broad agreement that the process involves intentional, reflective thinking to inform an action. This approach does not presume that one will likely be wrong. It often leads to an examination of various options, but it is not realistic to identify every possible option. Critical thinking is not synonymous with criticizing others
A student nurse has been challenged to apply the principles of critical thinking during laboratory simulations. What characteristic of the student nurse's actions suggests that the student nurse engaged in critical thinking?
The nurse is an expert, according to Benner's novice-to-expert model of development Intuition is a marker of an "expert" in Benner's model. Rest's framework (which contains moral sensitivity and moral judgment) focuses on ethics rather than information-processing and meaning-making. Expert nurses do not practice beyond their legally defined scope.
A student nurse who is soon to graduate is completing a preceptorship with a nurse who has many years of clinical experience. The student has marveled at the nurse's ability to derive meaning from complex and rapidly changing situations, relying heavily on nurse intuition. What characteristic of this nurse does this ability demonstrate most clearly?
The nurse is an expert, according to Benner's novice-to-expert model of development. Intuition is a marker of an "expert" in Benner's model. Rest's framework (which contains moral sensitivity and moral judgment) focuses on ethics rather than information-processing and meaning-making. Expert nurses do not practice beyond their legally defined scope.
A student nurse who is soon to graduate is completing a preceptorship with a nurse who has many years of clinical experience. The student has marveled at the nurse's ability to derive meaning from complex and rapidly changing situations, relying heavily on nurse intuition. What characteristic of this nurse does this ability demonstrate most clearly?
Gather objective and subjective assessment data. Inductive reasoning requires observing, then drawing conclusions. That is, the process begins with data (such as assessment findings) and then progresses to identification of patterns or explanations. Presupposing the client's challenges or diagnoses would be contrary to this linear process. Beginning with a principle or theory is consistent with deductive reasoning.
An experienced nurse has received a new client and will apply the principles of inductive reasoning in the care-planning process. What action will the nurse perform first when applying this form of clinical reasoning?
increased mucus production Oxygen saturation levels and shortness of breath are considered signs and symptoms and are related to the client's problem (diagnosis) of pneumonia. Increased mucus production is a root etiologic factor that results from the diagnosis and results in the signs and symptoms.
For the purposes of planning a client's care, which factor will the nurse categorize as an etiologic factor?
The nurse is unsure whether a particular intervention is in the nursing scope of practice. The American Nurses Association (ANA) produces Nursing: Scope and Standards of Practice. The National Council of State Boards of Nursing (NCSBN) administers the NCLEX. Quality and Safety Education in Nursing (QSEN) competencies are not within the purview of the ANA. Various organizations provide information and guidance on working with students, but this is not specific to the ANA.
For which scenario will the nurse consult resources from the American Nurses Association?
reflection on-action Reflection on-action involves a debrief or postconference. It occurs after the situation and drives clinical learning. Reflection in-action happens in the moment. Noticing involves the perception of cues near the beginning of the interaction, and interpreting is characterized by assigning meaning to the cues that were noticed.
The community health nurse is participating in a debrief about a critical incident that involved a physical altercation with the client in the client's home. When applying Tanner's model of clinical judgment to this situation, the debriefing exercise constitutes what component of the model?
Respond by selecting the appropriate interventions The continuum of nursing actions within Tanner's model progress from noticing (perceiving the client's behavior), interpreting (making meaning of the behaviors), to responding. Responding is characterized by choosing appropriate actions. Reflection is central to the model, but passive monitoring would not be a sufficient response to the client's behavior, which warrants the nurse's input.
The community nurse has entered a client's home and noticed that the client is agitated and exhibits restless body language. The nurse has interpreted these behaviors as a sharp departure from the client's usual behavior and has discerned that the behavior is related to a recent family conflict. Within Tannner's model of clinical judgment, what will the nurse do next?
assessing the client's risk for suicidal ideation during the visit Assessing for suicidality is a direct and tangible expression of safety. Each of the other listed actions is consistent with safety but in a less direct manner. Rapport-building and offering support are most closely aligned with client-centered care. Assessment is also related to safety but in a less direct manner than determining suicide risk
The home health nurse is performing a home visit to a client who has been diagnosed with postpartum depression. How can the nurse best demonstrate the Quality and Safety Education for Nurses (QSEN) competency of safety during this home visit?
evaluating the client's pain 30 minutes after administering the analgesia Evaluating outcomes is the final step in the CJMM. All of the actions listed are appropriate, but evaluation is the most direct indication of this sixth and final step
The nurse has provided analgesia to a client who was reporting pain, and the nurse used the NCSBN Clinical Judgment Measurement Model (CJMM) to inform the process. What action by the nurse represents the final step in this model?
evaluating the client's pain 30 minutes after administering the analgesia Evaluating outcomes is the final step in the CJMM. All of the actions listed are appropriate, but evaluation is the most direct indication of this sixth and final step.
The nurse has provided analgesia to a client who was reporting pain, and the nurse used the NCSBN Clinical Judgment Measurement Model (CJMM) to inform the process. What action by the nurse represents the final step in this model?
The nurse is able to rapidly discern between important and unimportant data while assessing a new client. Situational awareness (SA) is "the perception of the elements in the environment in a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future" (Endsley, 1995). That is, being able to rapidly determine salient data from benign data. This goes beyond simply multitasking, alertness, or high arousal, and involves skilled differentiation of constantly changing data. Reflection, in its different forms, is a marker of a skilled nurse, but this is not synonymous with SA.
What circumstance best shows that the nurse possesses advanced situational awareness (SA)?
noticing interpreting responding reflecting Tanner's model represents an interactive process that generally follows the sequence of noticing, interpreting, responding and reflecting (both on-action and in-action).
The nurse is applying Tanner's Clinical Judgment Model in the care of a client. Building off the context and background information, place the components of the model in the correct sequence. Use all options.
moral judgment/reasoning Moral judgment/reasoning involves consideration of several courses of action to account for the potential impact on those involved. This is tantamount to generating solutions. Moral sensitivity involves awareness of ethics. Moral motivation is the cognitive process of decision-making. Moral character is the actual implementation of a plan.
The nurse is applying the Clinical Judgment Measurement Model (CJMM) to the care of a client who has been expressing anxiety. The nurse has recognized and analyzed the various cues that the client is exhibiting, has prioritized hypotheses that may explain the client's anxiety, and is now generating possible solutions. In this particular stage of the CJMM, the nurse is demonstrating which component of Rest's framework of moral reasoning?
an etiologic factor. Etiologic factors are the root phenomenon that results in signs and symptoms, such as bleeding. The client's bleeding is a result of the inhibitory action of the NSAIDs on platelet function. "Upper GI bleed" is the client's diagnosis
The nurse is caring for a client who has an upper gastrointestinal bleed as a result of excessive use of nonsteroidal anti-inflammatory drugs (NSAIDs). The nurse recognizes that the root of the client's health problem is inhibited platelet action. The nurse considers the inhibited platelet action to be:
information-processing model The rote, linear approach to addressing issues that disregard client complexities is the information-processing model. Each of the other listed models integrates the complex, human realities of nursing practice.
The nurse is describing a clinical encounter, stating, "I entered the room, gathered assessment data, and then provided the interventions specified in standard operating procedures." The nurse is applying which conceptualization of clinical decision-making?
Interprofessional Education Collaborative Active collaboration between health professions is the cornerstone of the Interprofessional Education Collaborative (IPEC) competencies. The actions are wholly consistent with the values of the other listed organizations, but the interdisciplinary nature of this action is a direct and practical example of IPEC competencies.
The nurse is participating in a client conference for a client who has complex health needs. The client's psychiatrist, occupational therapist, and social worker are also participating in the conference. The nurse is most clearly demonstrating the values of what organization?
coordinating with the physical therapist to amend a client's activity orders in the plan of care Interprofessional Education Collaborative (IPEC) competencies go beyond carrying out orders from another profession, reporting to a member of another profession, or one-way learning from another profession. Active collaboration on client care, such as working together on activity orders, demonstrates the participatory nature of the competencies.
What action by the nurse in a hospital setting best exemplifies the goals of the Interprofessional Education Collaborative (IPEC) core competencies?
