INTRO TO CJMM

Clinical judgement is defined as the observed outcome of which processes?

- Critical thinking - Decision making

3 Functions of Layer 2:

- Form Hypotheses - Refine Hypotheses - Evaluation

Which activities would the nurse perform when a clinical situation occurs according to layer 1 of the Clinical Judgment Measurement Model?

- Seek new knowledge The nurse seeks new knowledge, recognizing that there are seldom clear, "one size fits all" solutions. -Respond appropriately -The nurse should be flexible and respond timely, as appropriate for the unique situation. -Consider influencing factors The nurse considers all factors that might influence the particular patient's circumstances. -Recognize what is happening The nurse must clearly understand what is happening with the patient to respond appropriately. -Interpret the meaning of the situation Clinical judgment is complex, and every patient experiences unique health problems. The nurse must accurately interpret the meaning of the situation to provide safe, competent care.

Which components are addressed by layer 1 of the Clinical Judgment Measurement Model (CJMM)?

- Unobservable cognitive operations Layer 1 is a cognitive layer of the CJMM that includes unobservable cognitive operations. -Observable outcome of critical thinking

Which characteristic describes the influence of context on clinical judgment? -Does not affect decision making -Promotes standardization of patient care -Affects the understanding of the patient situation -Identifies environmental factors as internal influences

-Affects the understanding of the patient situation Context is defined as aspects that influence the understanding of an event, circumstance, or condition.

Recognize Cues

-Collect cues from a variety of sources: Objective data: observation of behaviors and interactions, physical assessment, medical record, laboratory reports, diagnostic findings, and so on Subjective data: health history and reports from family, caregivers, health care team, and so on. Consider the following questions when collecting data: -What information is relevant/irrelevant? -What information is most significant? -What information requires immediate attention?

Identify Outcomes to Generate Solutions

-Expected patient outcomes and goals are identified based on the identified priority hypotheses. Examples include the following hypotheses and outcomes: Pain: The patient will verbalize a pain level of 3 or below on a 0-10 pain scale by postoperative day 2. Risk for Infection: The patient will demonstrate how to clean the wound before discharge. Activity Intolerance: The patient will ambulate the length of the hall with assistance 3 times each day within 2 days of surgery. Solutions/actions are defined to support achievement of outcomes and goals and align with evidence-based practice guidelines. Examples include the following hypotheses and actions:Pain: Administer prescribed medication(s).Risk for Infection: Provide patient education regarding process to clean wound.Activity Intolerance: Assist patient to ambulate. Solutions that should be avoided due to contraindications are also noted.

Analyze Cues

-Organize and link cues to the patient's actual or potential clinical condition, much like putting pieces of a puzzle together. The nurse places similar or related "puzzle pieces" (cues) together to form a picture (hypothesis). Consider the following questions when analyzing data: -Which patient conditions are consistent with the collected cues? -Do any cues support or refute a particular condition? -Why is a particular cue or subset of cues of concern? -What other information would help establish the significance of a cue or set of cues? -More than one problem can exist. Consider that multiple things could be happening at the same time, which can affect the patient's clinical presentation and condition. -The nurse connects related cues together to form the hypotheses that are most appropriate for the patient's unique circumstances.

Layer 1: Clinical Judgement

Defined by the observable outcome of critical thinking and decision making depicted in layer 0 and the unobservable cognitive operations depicted in layers 2 and 3 Clinical judgment is an essential component of nursing practice as it allows nurses to observe changes in patient status, recognize potential problems, and take immediate action when needed. Initially, the nurse might not have a clear or accurate understanding of a patient's needs and the appropriate actions to take. The nurse should question and explore different perspectives and interpretations to find the best solution for the patient, and the CJMM provides a framework for the nurse to apply these clinical judgment skills.

3 Steps that support completion of the 3 functions of Layer 2:

-Recognize and analyze cues (to form hypotheses in layer 2) -Prioritize hypotheses and generate solutions (to refine hypotheses in layer 2) -Take actions and evaluate outcomes (to complete the evaluation process in layer 2).

Which step of layer 3 of the Clinical Judgment Measurement Model involves organizing and linking cues to the patient's clinical condition? Analyze cues Recognize cues Generate solutions Observe patient needs

Analyze cues During the "analyze cues" step of layer 3, the nurse organizes and links cues to the patient's actual or potential clinical condition, much like putting pieces of a puzzle together. The nurse places similar or related "puzzle pieces" (cues) together to form a picture (hypothesis).

Which characteristic describes patient needs as they relate to layer 0 of the Clinical Judgment Measurement Model?

Are influenced by clinical decisions. Clinical decisions made at the completion of the clinical judgment process affect patient needs.

Layer 0: Observable Components

Clinical Needs: Identification of patient needs initiates the process of clinical judgment. Clinical decisions made at the completion of the clinical judgment process affect patient needs. Definition of patient needs: what is needed or desired to improve overall health. Examples of patient needs: personal care/hygiene needs, symptom/disease management, emergent care, emotional support, spiritual needs, cultural needs, health promotion, infection control, medication management, and pain relief. Clinical Decisions: Clinical decisions conclude the clinical judgment process. Clinical decisions are influenced by the entire clinical judgment process.

Match the type of contextual factors influencing clinical judgement w/ appropriate examples.

Education, Experience, Knowledge - internal contextual factors Distractions, time pressures, time complexity - external contextual factors

Which description best explains how contextual factors affect the way nurses communicate? Encourage the nurse to recognize new insights Promote collaboration to develop a standardized plan of care Encourage the nurse to make decisions based on prior patient care experiences Allow the nurse to make conclusions based on preliminary understanding of the situation

Encourage the nurse to recognize new insights Consideration of context during communication allows the nurse to recognize new insights that are shared during the conversation.

Evaluate Outcomes

Evaluation requires the nurse to compare observed outcomes to expected outcomes and develop a conclusion as to whether conditions have improved, declined, or remained unchanged. Evaluation of outcomes involves the following competencies: -Collaborate and communicate with patients and family members regarding the plan of care to ensure that the patient's perspective is included. -Collaborate and communicate with members of the health care team to develop and revise the plan of care. -Incorporate ongoing assessment data and patient cues to update and revise the plan of care as needed. -Document evaluation information.

Prioritize Hypotheses

Hypotheses are evaluated and ranked based on priority: -Likelihood of occurrence -Urgency -Risk for complication -Prioritization of hypotheses establishes a preferential order for solution generation and nursing actions. -Prioritization is important to assist the nurse in anticipating patient needs and planning care, particularly when a patient has multiple diseases, conditions, or injuries happening simultaneously.

Which sources would the nurse use to collect objective patient cues? Select all that apply. Laboratory report Health history Medical record Family interview Physical assessment

Laboratory Report Medical Record Physical Assessment

Layer 2: Form Hypotheses - Refine Hypotheses - Evaluation

Layer 2 of the CJMM represents a cyclical, or recurring, process of three cognitive operations: forming hypotheses, refining hypotheses, and evaluating outcomes.

Match the layers of the Clinical Judgment Measurement Model with the concept addressed in each layer.

Observation: layer 0 Hypotheses: layer 2 & 3 Clinical Judgement: layer 1 Contextual Factors: layer 4

Layer 2: Refining Hypotheses

Once the hypotheses are developed, the nurse refines them to ensure that the patient's priority needs are met in the most appropriate manner. It is important to remember that patients who present with similar disease processes or injuries may not actually have the same plan of care. The hypotheses are prioritized and solutions are generated based on the priority concerns to develop a plan of care to meet the unique needs of each individual patient.

Evaluating Outcomes

Questions the nurse can ask to evaluate actual or observed outcomes against expected outcomes are as follows: -What signs would indicate improvement or a positive outcome? -What signs would indicate a decline or a negative outcome? -What signs would suggest that the patient's status has not changed? -Were the solutions/interventions effective? -What other solutions/interventions might have been more effective? -Should the nurse revise any components of the plan of care to best meet the patient's needs?

Take Action

The nurse takes action by implementing the solutions that address the highest-priority issues. Taking action involves different tasks, such as the following: -Teaching (e.g., educating a patient regarding how to self-administer insulin) -Requesting (e.g., asking the health care provider to provide prescriptions for pain medication or diagnostic testing) -Performing various nursing skills -Administering medications or other prescribed treatments -Documenting actions, findings, patient status, outcomes, and so on -Communicating with family, caregivers, and other members of the health care team -Actions should be patient-centered. Appropriate actions may not look the same for different patients experiencing similar conditions.

Generate Solutions: Supporting Interventions

There are three types of interventions: Nurse-initiated interventions (independent): The nurse autonomously initiates interventions without a prescription from the health care provider or direction from others. State Nurse Practice Acts often outline these interventions. Example: Teaching patients about medication management. Health care provider-initiated interventions (dependent): Actions require a health care provider prescription and are a component of managing a medical diagnosis. Examples: Medication administration and invasive procedures. Collaborative interventions (interdependent): Actions necessitate expertise and skill of multiple health care team members across disciplines. Example: Patient recovering from surgery is prescribed pain medication by the health care provider, medication is administered by the nurse, and exercises are implemented by the physical therapist.

CJMM LAYERS Layer 0 Layer 1 Layer 2 Layer 3 Layer 4

layer 0: observation; layers 1 to 3: cognitive operations; and layer 4: individual and environmental contextual factors.