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This course explores the concepts of critical thinking, clinical reasoning, and clinical judgment and their relationship to the new graduate nurse transitioning to practice. It also reviews strategies that healthcare organizations can use to bridge the education-to-practice gap and foster the development of clinical judgment.

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Fostering Clinical Judgment in New Nurses

Disclosure Statement

Upon completion of this module, learners should be able to:

describe the steps of the nursing process
explore the relationship between critical thinking, clinical reasoning, and clinical judgment
discuss the impact of clinical judgment on patient outcomes
explore strategies to foster the development of clinical judgment in new graduate nurses

Nurses are responsible for offering high-quality, evidence-based care to optimize patient outcomes. As new treatments emerge, people are living longer, healthier lives. As the US population ages, more people live with chronic health conditions. These conditions have created a clinical environment that is more complex than ever before. The demands of the complex clinical environment require that nurses multitask and make sound clinical decisions when providing patient care. The National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP; 2022) defines chronic diseases as conditions that last more than 1 year, require ongoing medical attention, and/or limit activities of daily living (ADLs). Chronic disease is the leading cause of death and disability in the US. An estimated 6 out of 10 American adults have at least one chronic disease, and 4 out of 10 have two or more chronic diseases. Chronic conditions such as heart disease, cancer, chronic lung disease, diabetes mellitus (DM), Alzheimer's disease, and chronic kidney disease (CKD) significantly contribute to the increasing complexity of care in the clinical environment (Manetti, 2019; NCCDPHP, 2022).

New graduate nurses entering the clinical setting encounter various challenges in delivering safe and effective patient care. It is estimated that only 8% of new graduate nurses are prepared to make entry-level clinical judgments, creating an education-to-practice gap. Poor clinical judgment can lead to poor patient outcomes. New graduate nurses must be provided with focused training and clinical insight into promptly and appropriately identifying patient needs. This skill set requires knowledge about medical conditions and disease processes, the principles of medication administration, pharmacokinetics, and adverse effects, as well as the ability to appropriately apply this information to meet individual patient needs. Experienced nurses have acquired and developed clinical judgment through trial and error while delivering patient care. Due to staffing and resource shortages, new graduate nurses are expected to hit the ground running, delivering safe and effective care in a fast-paced healthcare environment with high patient acuity, patient-to-nurse ratios, and complex clinical conditions despite their lack of experience. To ensure that new graduate nurses are prepared for these demands upon entering the clinical setting, recurrent application and intentional practice of clinical judgment must occur during their education (Kavanagh & Szweda, 2017; Rose, 2020).

Nursing Process

The nursing process, a systematic problem-solving approach for designing and implementing individualized care, is the foundation of the nursing profession. The nursing process can be used across all care settings with patients of all ages to identify and treat potential or actual health problems while incorporating each patient's unique aspects. The process is dynamic and cyclical, supporting evidence-based practice (EBP) to guide decision-making (Craven et al., 2021). The nursing process has six phases (Craven et al., 2021):

Assessment is evaluating a patient's health, including the physical, psychological, sociocultural, emotional, and spiritual factors that may impact that health state.
Diagnosis is the clinical act of identifying problems by analyzing assessment information and deriving meaning from the findings (i.e., nursing diagnosis).
Outcome identification involves formulating and documenting realistic, measurable, patient-focused goals.
Planning is working collaboratively with the patient to identify goals and intervention strategies to address priority problems. The written care plan provides a summary of the care the patient is to receive.
Implementation is the action phase of the nursing process when the nurse initiates the plan of care, documenting the nursing interventions and the patient's response to the interventions.
Evaluation refers to the rating, grading, and judging whether the patient's care plan was successful.

Clinical Judgment
While several terms are used interchangeably to describe the competencies needed to deliver safe and effective patient care, they have different meanings; nursing leadership should understand the distinctions among them to foster clinical judgment for new graduate nurses (Alfaro-Lefevre, 2017). The following terms are interrelated and represent essential processes that lead to the comprehensive application of EBP (Alfaro-Lefevre, 2017; Connor et al., 2022).
Critical thinking is a broad term that includes reasoning inside and outside the clinical setting.
Clinical reasoning is the process used to consider issues at the patient's bedside or point of care to prevent or manage a problem.
Clinical judgment is a nurse's conclusion, decision, or opinion after considering all available data based on reflection, critical thinking, and clinical reasoning.

There have been conversations on the use of critical thinking versus the nursing process by nurse education experts. The American Nurses Association (ANA) standards state that the nursing process serves as a critical thinking model that promotes the competent care of patients (ANA, 2015). Critical thinking, which leads to clinical reasoning and ultimately clinical judgment, is purposeful and informed outcome thinking that:

is guided by standards, policies, ethical codes, and laws
is driven by patient, family, and community needs, as well as nurses' needs to give competent and efficient care
is based on principles of the nursing process, problem-solving, and the scientific method
focuses on safety and quality, constantly re-evaluating, self-correcting, and striving to improve
carefully identifies the key problems, issues, and risks involved while including patients, families, and key stakeholders in decision-making early in the process
uses logic, intuition, and creativity and is grounded in specific knowledge, skills, and experience
calls for strategies that make the most of human potential and compensate for problems created by human nature (e.g., finding ways to prevent errors, using technology, and overcoming the powerful influence of personal views; Alfaro-Lefevre, 2017)

In 1985, Patricia Benner first noted that critical thinking was based on attitudes and skills relative to logic, rationality, and reasoning (Benner et al., 2009). A person's knowledge, skills, and attitudes (KSAs) drive critical thinking. The Quality and Safety Education for Nurses (QSEN, n.d.) competencies, which focus on positive patient outcomes, highlight the importance of KSAs in nursing education and for new nurses as they transition to practice. Nurses working in various clinical settings will encounter numerou

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s opportunities for critical thinking, including:

problem-solving, decision-making, or judgment
patient or caregiver safety
diagnostic reasoning (understanding and applying the nursing process)
delivering patient-centered care
applying moral and ethical reasoning
applying EBP to deliver care
using electronic medical data
personal self-improvement, stress management, or health promotion
improving patient outcomes and care delivery systems through quality improvement (Alfaro-Lefevre, 2017)

Given the complexity of the clinical environment, memorization-style thinking is insufficient to equip nurses with the skills to sort, organize, and interpret relevant information for effective and safe patient care. Instead, nurses must work with a broad knowledge base to individualize patient care across various clinical settings. Nursing education provides the foundation for critical thinking through experiences, reflection, communication, and observations. Then, clinical experience further develops critical thinking skills for new graduate nurses. Nurses encounter critical thinking and reflection opportunities when interacting with health and illness in the clinical setting. Nurses need to use the knowledge obtained in nursing school and clinical practice to create knowledge connections that foster critical thinking. Clinical reasoning occurs when nurses apply critical thinking by integrating theoretical knowledge with actual clinical experience. Nurses who are inquisitive and actively involved in their learning are more likely to foster sound clinical judgment successfully (see Table 1; Craven et al., 2021).

Table 1

Characteristics that Foster Critical Thinking and Clinical Reasoning

Critical Thinking

Clinical Reasoning

effective communicator
honest and ethical
insightful and analytical
flexible and improvement-oriented
self-aware, responsible, and accepting of accountability
inquisitive and looking for the rationale behind actions
intuitive and logical
reflective and self-correcting
resilient and confident
prudent with the delivery of care
sensitive to diversity, open-minded and fair, showing tolerance for others

applies a cyclical process involving cue acquisition and analysis to take appropriate actions within the required time to facilitate positive outcomes
uses formal and informal thinking strategies to gather and analyze patient information
evaluates the significance of gathered data and weighs alternative actions
can analyze, use logic, seek information, discriminate, apply standards, predict, and apply the knowledge
must have effective communication skills plus an appropriate educational level, knowledge, and ability to think critically, along with a familiarity with the environment and context of care

(Craven et al., 2021; Griffits et al., 2017)

Clinical judgment requires that critical thinking and clinical reasoning occur in care delivery. Tanner first described this concept in 2006 as "an interpretation or conclusion about a patient's needs, concerns, or health problems and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response" (p. 204). Tanner further develops a clinical judgment model from over 30 years of research synthesis, incorporating four aspects of clinical judgment: noticing, interpreting, responding, and reflecting (Tanner, 2006). According to this model, a nurse's judgment in the clinical setting involves the following:

a grasp of the clinical situation at hand and an awareness of it (noticing)
interpreting the situation and determining how to respond (interpreting)
deciding on an appropriate course of action (responding)
attending to the patient's responses to the action and assessing the situation (reflection)
reviewing the outcomes of the action while focusing on the appropriateness of all the preceding actions (reflection; Benner et al., 2009; Billings, 2019; Tanner, 2006)

Impact on Patient Outcomes

The quality of patient care depends on nurses who are prepared to recognize their needs and respond accordingly. Nursing judgment directly impacts the ability to apply EBP and to react to changes in the patient's condition. Hospitals have acknowledged the lack of student preparedness for years and implemented extended orientations, preceptorships, mentoring programs, and nurse residency programs to bridge the gap between the education and practice settings. The transition from novice nurse to an advanced beginner is filled with insecurities, a lack of experience, and a deficit of clinical judgment. Both patients and medical facilities benefit from nurses who can demonstrate competent clinical judgment. Lasater and colleagues (2015) found that only 13% of preceptors believed novice nurses could establish priorities and demonstrate safe nursing care. High-quality patient care depends on the nurse's competence and application of clinical judgment (Lasater et al., 2015). The National Council of State Boards of Nursing targets optimal outcomes for patients, nurses, and clinical organizations. Nurses should enter practice with the ability to make appropriate clinical decisions through clinical judgment (NCSBN, n.d.-b).

Despite organizational strategies to improve the safety and efficacy of patient care, preventable healthcare errors are the third leading cause of death in the US. New graduate nurses represent 6% of the nursing workforce and often enter practice with a basic skillset and limited experience with actual patient scenarios, which are essential for developing clinical judgment. Treiber and Jones (2018) conducted a mixed methods study to understand individual- and system-level factors surrounding medication errors by new graduate nurses. They found that 55% of new graduate nurses admit to making an error within their first 5 years of clinical practice (Treiber & Jones, 2018). Dynan and Smith (2022) investigated the relationship between hospital spending on continuing nurse education and staff on nurse-sensitive, patient-safety outcomes, including pressure ulcers, central venous catheter-related bloodstream infections, and deep vein thrombosis (DVT). The researchers found that one standard deviation increase in nursing education was associated with a 16% reduction in catheter-related bloodstream infection and a 5% reduction in DVTs (Dynan & Smith, 2022).

Developing Clinical Judgment

New graduate nurses may take several years to develop clinical competence and sound clinical judgment. Research indicates that regardless of education, experience is the most significant indicator of clinical judgment, particularly within specialty care areas such as intensive care or obstetrics (OB): nurses need three and six years of experience to demonstrate the highest levels of clinical judgment. Experienced nurses have an internalized ability to assess, apply knowledge and intuition, provide intentional thought in a situation, and collaborate with their peers and healthcare team to deliver safe and effective care. Nursing leaders must find ways to foster the development of clinical judgment in new graduate nurses. Nursing education is crucial in preparing new nurses to utilize the nursing process and exhibit clinical judgment (Lasater et al., 2015; Tanner, 2006).

In response to the information that new graduate nurses were not meeting the minimum expectations for safe and effective care upon entry into practice, the NCSBN generated a task model to measure clinical judgment. This model is used to frame the teaching and evaluation of the complex skill of clinical judgment. The NCSBN is further developing test items to evaluate prelicensure nursing students' ability to make safe and accurate clinical judgments. These test items will be added to the National Council Licensure Examination (NCLEX) test plan during the 2023 testing cycle. Before developing these test items, the NCSBN developed its clinical judgment measurement model, the NCJMM. Researchers from the NCSBN created the NCJMM as a "framework for the valid measurement of clinical judgment and decision making within the context of a standardized, high-stakes examination" (NCSBN, n.d.-a, para. 1). This model does not redefine clinical judgment but gives the NCSBN and nurse educators a method for measuring and deriving inferences around clinical judgment and the ability of entry-level nurses to make decisions that are safe and effective for positive patient outcomes. Six steps within this model define the clinical judgment process; see Table 2 for the steps and associated tasks (Billings, 2019; NCSBN, n.d.-a).

Table 2

Steps in the Clinical Judgment Process and Associated Tasks

Step	Tasks
1. Recognize cues	assess the patient review patient chart information consider the patient's views and desires differentiate relevant and irrelevant data
2. Analyze cues	determine patterns connect the cues discern concerning information decide if more information is needed
3. Prioritize a hypothesis	combine or cluster the information focus on the possibilities decide on prioritizations determine the risk of action or lack of action give evidence for the hypothesis
4. Generate solutions	consider several possible care options connect an understanding of the patient's needs to possible courses of action
5. Take action	implement the plan of action perform the skill or procedure administer medication collaborate with the healthcare team teach the patient or their family practice ethical and legal behaviors
6. Evaluate outcomes	determine if the desired outcomes were achieved determine if the actions were effective

(Billings, 2019; NCSBN, n.d.-a)

Strategies to Foster Clinical Judgment in New Graduate Nurses

The nursing profession has evolved significantly over the last few decades, shifting from task completion to skilled nursing care. Care provided by professional nurses and non-professional caregivers differs, with the professional nurse utilizing the nursing process to establish sound clinical judgment. Given the numerous challenges nurses face in the clinical environment (i.e., rapidly changing situations, high patient-to-nurse ratios, high acuity, and the prevalence of chronic conditions), critical thinking and clinical judgment are considered essential skills. Healthcare organizations must consider various strategies to support the development of clinical competence and clinical judgment in new nurses, including addressing the education-to-practice gap, mentoring, simulation-based learning, and new graduate nurse residency (NGNR) programs (Murray et al., 2019; Treiber & Jones, 2018).

Education-to-Practice Gap

The widening education-to-practice gap has challenged healthcare organizations to identify strategies to foster clinical judgment in nurses. The education of nurses has traditionally focused on classroom-based learning, supplemented with clinical experiences. However, research has suggested that these singular strategies are ineffective in preparing nurses for clinical practice. More specifically, academic programs often focus solely on the NCLEX pass rates as the measure of success. Healthcare organizations expect new graduate nurses to join the workforce highly competent and prepared to function in the complex healthcare environment. However, the reality is that many nurses do not meet the expectations for entry-level clinical judgment, potentially resulting in adverse outcomes. Healthcare organizations are tasked with identifying ways to eliminate the education-to-practice gap related to new graduate nurses' clinical judgment and competence. Even though there has been significant progress in defining the role of the professional nurse, a knowledge barrier still exists regarding understanding clinical judgment in nursing. An exploratory and descriptive qualitative study was conducted to evaluate the nurse's understanding of clinical judgment. The researchers found that participants had a primary and simplistic understanding of clinical judgment in nursing. More specifically, many nurses equated clinical judgment to good nursing care. Therefore, the first step to improving nurse competence and clinical judgment should be establishing and defining the relationship between a sound knowledge base, reasoning and critical thinking skills, and their impact on effective clinical decision-making (Kavanagh & Szweda, 2017; van Graan et al., 2016).

Mentoring

Mentoring or clinical role modeling is another strategy that can help foster competence and clinical judgment in new nurses. As new nurses transition from student to practicing nurse, they often experience a phenomenon known as transition shock. Transition shock is a non-linear movement through professional role transition that encompasses developmental, intellectual, skill, and role-relationship changes. Three stages of transition occur over 12 months, including doing, being, and knowing. Each stage is defined by psychological development that influences their skill development. During the early months of practice, new nurses find their idealistic expectations disparate from reality. Due to their limited clinical experience, new nurses often experience stress and anxiety, which is part of transition shock. Feelings of self-doubt and a lack of confidence can hinder the development of clinical judgment, potentially leading to adverse patient outcomes. Clinical mentors or role models can be critical in transitioning new nurses to practice. Successful role transitions can occur when new nurses work in a safe and supportive environment. Healthcare organizations must prioritize new nurse transition to practice by ensuring that effective mentors and role models are in place. Given the challenges in the clinical environment, including staffing shortages and insufficient role models, clinical judgment can be negatively impacted. Nursing leadership should employ methods to enhance communication and teamwork in their units to foster a safe and supportive environment. Positive interpersonal relationships and mentoring facilitate a trusting clinical environment that supports knowledge sharing, critical thinking, and clinical judgment (Murray et al., 2019; van Graan et al., 2016). Powers and colleagues (2019) found that nurse preceptors were critical to a successful transition to practice for new nurses. Effective nurse preceptors can build confidence, decrease anxiety, and foster clinical judgment (Powers et al., 2019).

New Graduate Nurse Residency Programs and Simulation-Based Training

In the Future of Nursing report, the Institute of Medicine (IOM) called for a foundational shift in nursing education and transition to practice. Research has supported the existence of the education-to-practice gap that leaves new graduate nurses with limited clinical experience to foster sound clinical judgment. NGNR programs are a newly developed model that healthcare organizations use to promote clinical skill acquisition, build confidence and competence, and encourage role socialization. These programs offer a structured transition-to-practice model that incorporates role modeling, communication, teamwork, skill building, simulation, and other opportunities for new graduate nurses to feel safe and supported in their transition to practice. Rush and colleagues (2019) evaluated the best practice of NGNR programs and found that these programs support nurse retention, satisfaction, and perceived competence. More specifically, confidence and competence were crucial aspects of NGNR programs, with nurses self-reporting increased knowledge, skill acquisition, communication, and clinical decision-making during challenging situations. When self-perceived confidence and competence are high, nurses are more likely to improve their critical thinking and clinical judgment (Rush et al., 2019). In a qualitative study evaluating new graduate nurses' perception of their evolving clinical reasoning and judgment, Wright and Scardaville (2021) found that reflective journaling was a key component of NGNR programs. The researchers concluded that reflective journaling is vital for the self-analysis of clinical decision-making for new nurses that can foster clinical judgment (Wright & Scardaville, 2021).

High-quality simulation-based training has been supported in the literature as an intervention to develop clinical judgment in prelicensure nursing students. Many healthcare organizations have begun to use simulation-based training for new nurses during their transition to clinical practice. This strategy allows healthcare leadership to provide experiential learning opportunities in a controlled, safe learning environment. Given that many new nurses are underprepared to manage high-acuity situations and demonstrate poor clinical judgment, simulation opportunities can help fill this gap. High-fidelity simulation (HFS) utilizes computerized software within the manikin to mimic conditions that would occur in a real clinical experience. During nursing school, simulation-based training is often focused on skill acquisition. Simulation-based training during the transition to practice can be used for high-risk, low-frequency scenarios that allow new nurses to experience these clinical situations in a safe environment with guided mentoring and reflection opportunities. Simulation fosters teamwork, communication, and collaboration, all predictors of sound clinical judgment. In a quasi-experimental study, Kim and colleagues (2018) evaluated the effect of simulation-based handoff training on clinical competence and judgment for new graduate nurses. They found that new graduate nurses who received simulation-based training had higher clinical competence regarding handovers and clinical judgment than those who received peer-learning training. Healthcare organizations and nursing leadership should consider incorporating simulation-based training for nurses to help foster clinical competence and judgment (Kim et al., 2018; Tyndall, 2022).

References

Alfaro-Lefevre, R. (2017). Clinical reasoning and clinical judgment: A practical approach (6th ed.). Elsevier.

American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). https://www.nursingworld.org/practice-policy/scope-of-practice

Benner, P., Tanner, C. A., & Chesla, C. A. (2009). Expertise in nursing practice: Caring, clinical judgment, and ethics (2nd ed.). Springer Publishing.

Billings, D. M. (2019). Teaching nurses to make clinical judgments that ensure patient safety. The Journal of Continuing Education in Nursing, 50(7), 300-302. https://doi.org/10.3928/00220124-20190612-04

Connor, J., Flenady, T., Massey, D., & Dwyer, T. (2022). Clinical judgement in nursing: An evolutionary concept analysis. The Journal of Clinical Nursing, 00, 1-13. https://doi.org/10.1111/jocn.16469

Craven, R. F., Hirnle, C. J., & Henshaw, C. M. (2021). Fundamentals of nursing: Concepts and competencies for practice (14th ed.). Wolters Kluwer.

Dynan, L., & Smith, R. B. (2022). Sources of nurse-sensitive inpatient safety improvement. Health Service Research, 57(6), 1235-1246. https://doi.org/10.1111/1475-6773.13979

Griffits, S., Hines, S., Moloney, C., & Nicholas, R. (2017). Characteristics and processes of clinical reasoning in nurses and factors related to its use: A scoping review protocol. JBI Database of Systematic Reviews and Implementation Reports, 15(12), 2832-2836. https://doi.org/10.11124/JBISRIR-2016-003273

Kavanagh, J., & Szweda, C. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses' clinical reasoning. Nursing Education Perspectives, 38, 57-62. https://doi.org/10.1097/01.NEP.0000000000000112

Kim, J. H., Hur, M. H., & Kim, H. Y. (2018). The efficacy of simulation-based and peer-learning handover training for new graduate nurses. Nurse Education Today, 69, 14-19. https://doi.org/10.1016/j.nedt.2018.06.023

Lasater, K., Nielson, A., Stock, N., & Ostrogorsky, T. (2015). Evaluating the clinical judgment of newly hired staff nurses. The Journal of Continuing Education in Nursing, 46, 563-571. https://doi.org/10.3928/00220124-20151112-09

Manetti, W. (2019). Sound clinical judgment in nursing: A concept analysis. Nursing Forum, 54, 102-110. https://doi.org/10.1111/nuf.12303

Murray, M., Sundin, D., & Cope, V. (2019). New graduate nurses' clinical safety knowledge by the numbers. Journal of Nursing Management, 27, 1384-1390. https://doi.org/10.1111/jonm.12819

National Center for Chronic Disease Prevention and Health Promotion. (2022). About chronic diseases. Centers for Disease Control and Prevention. https://www.cdc.gov/chronicdisease/about/index.htm

National Council on State Boards of Nursing. (n.d.-a). NCSBN clinical judgment measurement model. Retrieved December 18, 2022, from https://www.ncsbn.org/14798.htm

National Council on State Boards of Nursing. (n.d.-b). Next generation NCLEX project. Retrieved December 18, 2022, from https://www.ncsbn.org/next-generation-nclex.htm

Powers, K., Herron, E. K., & Pagel, J. (2019). Nurse preceptor role in graduate nurses’ transition to practice. Dimensions of Critical Care Nursing, 38(3), 131-136. https://doi/org/10.1097/DCC.0000000000000354

Quality and Safety Education for Nurses. (n.d.). Graduate QSEN competencies. Retrieved December 18, 2022, from https://qsen.org/competencies/graduate-ksas

Rose, K. (2020). Creative tips for teaching clinical judgment. https://www.wolterskluwer.com/en/expert-insights/creative-tips-teaching-clinical-judgment

Rush, K. L., Janke, R., Duchscher, J. E., Phillips, R., & Kaur, S. (2019). Best practices of formal new graduate transition programs: An integrative review. International Journal of Nursing Studies, 94, 139-158. https://doi.org/10.1016/j.ijnurstu.2019.02.010

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. https://doi.org/10.3928/01484834-20060601-04

Treiber, L. A., & Jones, J. H. (2018). After the medication error: Recent nursing graduates' reflection on adequacy of education. Journal of Nursing Education, 57(5), 275-280. https://doi.org/10.3928/01484834-20180420-04

Tyndall, D. (2022). Effect of manikin and virtual simulation on clinical judgment. Journal of Nursing Education, 61(12), 693-699. https://doi.org/10.3928/01484834-20221003-03

van Graan, A. C., Williams, M. J. S., & Koen, M. P. (2016). Professional nurses' understanding of clinical judgement: A contextual inquiry. Health SA Gesondheid, 21, 280-293. https://doi.org/10.1016/j.hsag.2016.04.001

Wright, J., & Scardaville, D. (2021). A nursing residency program: A window into clinical judgement and clinical decision making. Nurse Education in Practice, 50, 102931. https://doi.org/10.1016/j.nepr.2020.102931

Fostering Clinical Judgment in New Nurses Nursing CE Course

About this course:

Course preview

Single Course Cost: $6.00

Fostering Clinical Judgment in New Nurses Nursing CE Course

About this course:

Course preview

Single Course Cost: $6.00

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