Webster University Uses a Clinical Judgment Model as a Framework for Graduate Assignments

Written by Stephanie Dribben, DNP, RN, ACNP-BC and Assistant Professor Janice L. Palmer, PhD, RN, CNE, Associate Professor

Since the announcement of the Next Generation NCLEX by the National Council of State Boards of Nursing, clinical judgement measurement models have received increased attention as frameworks for clinical decision-making. A clinical judgement framework can also be used to guide development of assignments and other learning experiences to broaden interpretations and responses beyond one’s background, experiences, and working knowledge. For example, Webster University used Tanner’s clinical judgement framework (2006) to develop a graduate student assignment. A goal of intentionally working through the components of the clinical judgement model with an assignment is to help students recognize the influence of one’s experiences, background, and assumptions in everyday clinical judgement while enhancing recognition of the value of listening to client preferences and using evidence-based theories and practice in determining goals and expected outcomes. Students form initial hypotheses and refine them as they collect more data points by working through the assignment.

For Webster University’s pathophysiology and application courses, students complete an in-depth study of a client’s physiological responses to disease and illness by integrating assessment findings, pathophysiology, and knowledge about interventions into formulation of a teaching plan. This multi-step assignment includes completing a comprehensive health questionnaire, processing and interpreting the information obtained, identifying client problems, deciding on a course of action, and reflecting-on-action and -in-action.

Students identify an individual in the community with at least one known chronic illness or significant health risk factor for which they are being treated and regularly monitored. The student and client work together to complete a comprehensive health questionnaire that includes personal status, family and social relationships, diet and nutrition, functional ability, mental health, personal habits, health promotion activities, and environment. In step two, students use the information obtained during the health interviews to develop a case study that describes the etiology and pathogenesis, clinical manifestations, diagnostic criteria, and current management of the chronic health condition(s). Students also review the literature to compare the client’s current treatment to best practice.

Based on the information from step two, students identify three health-related problems present now or potentially in the future for the client. When identifying problems, students are encouraged to take a holistic approach by considering current medications, potential side effects of long-term medication use, short- and long-term effects of chronic illnesses, health literacy, and the extent of social, family, and economic support.

The first three steps of the project correspond with “noticing” and “interpreting” in Tanner’s model of clinical judgment. Noticing is the nurses’ recognition of important aspects or perceptual grasp of a situation and is influenced by a nurse’s relationship with the client, previous experience with similar situations, and values related to a particular situation (Tanner, 2006). Interpreting is the development of a deeper understanding of the situation by interpreting the meaning of the data, which allows the nurse to respond appropriately.

Determining a course of action is the focus of step four. Using the information acquired in the previous steps, the student works closely with the client to establish realistic and achievable goals for current and future care. The student also develops an evidence-based teaching plan using current literature and guidelines, ensuring the information is appropriate for the client’s level of health literacy and provided in a way that best suits the client.

The final step of the assignment is reflecting. Student reflections include reflection-in-action and reflection-on-action. Reflection-in-action is the nurses’ assessment of how the client is responding to the intervention (Tanner, 2006). Students reflect on the client’s response to the established goals and provided teaching materials. Students also identify potential outcomes for the client as might be expected with successful, partial, or no follow-through. Reflection-on-action completes the cycle of clinical judgment and contributes to the development of the nurses’ clinical knowledge by reflecting on the entire experience and what was learned (Tanner, 2006). For this, students are asked to reflect on the entire experience including the clinical judgment process.

Since implementation in Fall 2020, the most significant challenge for students in completing the assignment has been the COVID-19 pandemic as social distancing guidelines (especially for at-risk clients) have limited students’ access to members of the community. However, the assignment has had positive feedback, especially from those working in acute care settings where the opportunity to develop a strong relationship with clients is limited by time. Faculty use the clinical judgement model too as they use ever-expanding data points to revise the assignment to better support achievement of related end-of-program student learning outcomes. Finally, this assignment is congruent with ACEN Criterion 4.4 in that it helps to prepare graduates to be information-literate and to practice from an evidence-based approach, with Criterion 4.5 as it supports recognition of cultural and ethnic diversity of clients, and with Criterion 4.9 as it reflects contemporary practice and nationally established patient health and safety goals and supports achievement of the end-of-program student learning outcomes.