Clinical judgment is a cognitive skill that is essential for nurses to develop to promote safe patient care outcomes. The National Council of State Boards of Nursing (NCSBN) (National Council of State Boards of Nursing, 2019) defines clinical judgment as:

the observed outcome of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe and assess patient situations, identify a prioritized client concern, and generate the best possible evidence-based solutions to deliver safe client care (p. 1).

Nursing research indicates that a lack of clinical judgment accounts for up to 65 % of nursing errors, with 55 % being medication errors (Lasater, 2007; National Council of State Boards of Nursing, 2018; Tanner, 2006; Treiber & Jones, 2018). Researchers highlight the need to develop clinical judgment in nursing school; however, barriers include a lack of evidence to support best practice clinical judgment teaching strategies, faculty hesitancy to use new strategies, and the theory-practice (Cappelletti, Engel, & Prentice, 2014; Kavanagh & Szweda, 2017; Lasater, Nielsen, Stock, & Ostrogorsky, 2015; Nielsen, Lasater, & Stock, 2016). A clinical judgment model (CJM) can be used to develop and evaluate students' attainment of clinical judgment (Dickison et al., 2019). However, faculty must have education on the CJM and how to integrate the model into the course curriculum.

Longitudinal data from the senior year complex care nursing course in one baccalaureate, pre-licensure nursing program showed that students performed poorly on application and analysis level test questions requiring higher levels of cognitive reasoning. The performance was demonstrated by low exam scores. Over the last three years, the cohort size in this urban, private, midwestern university averaged 81 students per year. Course data from 2019 to 2021 showed that up to 66 % of students did not meet the passing threshold or barely passed the first exam, whereas, on the second exam, up to 48 % of students were below the passing threshold or just passed the exam (with a score of 78 % deemed passing). In addition to the low exam scores, there was a decline in National Council Licensure Examination (NCLEX) first-time pass rates from 91 % in 2018 to 78 % in 2021 (Minnesota Board of Nursing, n.d.). The data is concerning as students close to graduation should be reasonably proficient in Bloom's higher-level taxonomy questions associated with sound clinical judgment.

With the low exam scores and decreasing NCLEX pass rates, faculty are ethically obligated to utilize best practices to foster and improve clinical judgment. The NCSBN developed its CJM to validate that safe levels of clinical judgment in entry-level nurses exist by creating and implementing the Next Generation (Next Gen) NCLEX. Educating faculty on using the CJM to guide their teaching and evaluation was identified as a possible evidence-based solution. A faculty needs assessment survey conducted in Spring 2022 included 19 full and part-time prelicensure faculty. Results indicated that 42 % of faculty were not confident in utilizing the NCSBN-CJM to guide teaching and evaluation, 32 % were neither confident nor unconfident, and only 26 % were confident (Rick, 2022). Survey results indicated the need for faculty education and support to teach and evaluate student attainment of clinical judgment. Results of the needs assessment also prompted the lead author to explore whether the NCSBN-CJM provided a suitable conceptual framework to guide faculty teaching, learning, and evaluation of student clinical judgment. The purpose of this article is to review the literature on clinical judgment models and describe the implementation of the NCSBN's CJM in one nursing curriculum.

A literature search occurred using the Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete and ProQuest Education databases. The search terms included the following keywords: nursing education, nursing faculty, nursing instructor, nurse educators, clinical judgment model, and clinical judgment. Inclusion criteria were English language, full text, peer-reviewed, primary research, and expert opinion from 2006 to 2022. Exclusion criteria included findings that only pertained to students and did not have implications for faculty or teaching. Nine articles that met the criteria were identified. Using thematic analysis, the following themes were identified: 1) the need for faculty CJM education; 2) the use of a CJM to guide various learning activities and evaluate student clinical judgment; and 3) strategies to integrate the NCSBN-CJM across the nursing curriculum.

The need for faculty development to use CJMs is a major theme in the literature (Brown Tyo & McCurry, 2019; Christensen et al., 2017; Dillard et al., 2009; Nielsen et al., 2016). Educators must first have knowledge of CJMs and how to evaluate clinical judgment before they can develop students' clinical judgment. A faculty development session is one way to increase nurse educators' knowledge of CJMs. Dillard et al. (2009) highlighted a successful CJM faculty development workshop and emphasized the importance of ongoing mentoring by knowledgeable peers to implement the CJM successfully.

A second theme in the literature includes recommendations for faculty use of CJMs to guide learning activities that promote and evaluate student clinical judgment (Dickison et al., 2019; Dillard et al., 2009; Lasater et al., 2015; Nielsen et al., 2016). CJMs can be applied to develop many different types of learning activities and strategies, including simulation, reflection papers, case studies, and exam test items (Dickison et al., 2019; Dillard et al., 2009; Lasater et al., 2015). Other studies demonstrated that the use of a CJM with a rubric is an effective means to evaluate student clinical judgment (Dillard et al., 2009; Kavanagh & Szweda, 2017; Klenke-Borgmann, Cantrell, & Mariani, 2020; Lasater et al., 2015; Nielsen et al., 2016). Lasater et al. (2015) describe how the use of a CJM and rubric provides an opportunity to evaluate and create learning activities to prepare students for future practice, thereby addressing the theory-practice gap. However, faculty must be educated on how to use CJMs with various course activities to support student clinical judgment development effectively.

The NCSBN created its CJM, which guides new test item types to better evaluate clinical judgment via the Next Gen NCLEX (Dickison et al., 2019). This new model captures the critical components that contribute to student clinical judgment (Dickison et al., 2019; Hensel & Billings, 2020). The model identifies variables that influence clinical judgment and highlights the cognitive components, which include recognizing and analyzing cues, prioritizing hypotheses, identifying solutions, taking appropriate action, and evaluating outcomes.

Several clinical judgment experts recommend the implementation of the NCSBN-CJM within the nursing curriculum, with an emphasis on the cognitive aspects of the model (Dickison et al., 2019; Hensel & Billings, 2020). In contrast, Ignatavicius (2021) identifies that the creation of the NCSBN-CJM was not to guide the nursing curriculum but to evaluate clinical judgment through systematic processes of test item development and evaluation. However, Ignatavicius (2021) concedes that the NCSBN-CJM is an action model that takes learning deeper than the nursing process alone for developing clinical judgment. Experts agree faculty can implement the model in nursing curriculum to support clinical judgment through the use of clinical cases; the think-aloud approach where faculty model the clinical judgment process; the use of prompts that guide students through the CJM cognitive; and the use of assessments to evaluate clinical judgment (Dickison et al., 2019; Hensel & Billings, 2020).

To summarize, the literature supports CJM faculty education to guide the development of student learning activities and to evaluate student development of clinical judgment; however, this recommendation is not without limitations. One weakness is the lack of research on using CJMs in nursing education, particularly regarding faculty development. Additionally, there is no valid and reliable tool available to assess faculty knowledge and confidence in using the NCSBN-CJM. Although many experts support using the NCSBN-CJM framework to guide learning activities across the nursing curriculum, it was not initially designed for that purpose. The CJM was designed as a measurement tool that would allow the NCSBN to depart from using solely dichotomous “right-wrong” answers. While easy to score, dichotomous questions are unable to capture the complexity of clinical judgment (Dickison et al., 2019). The NGN-NCLEX aims to measure students' ability to recognize, interpret, prioritize, and respond to and evaluate contextual factors in nursing practice to demonstrate that entry-level nurses can safely meet the demands of clinical practice (Dickison et al., 2019; Hensel & Billings, 2020; Ignatavicius, 2021).

The NCSBN-CJM was the guiding framework for this project. Fig. 1 shows the different layers of this model in more detail, starting from the foundational level of Layer 0 to the cognitive aspects of the clinical judgment process in Layer 3 and the contextual factors in Layer 4 (National Council of State Boards of Nursing, 2019). Layer 3 of this model guided this project and comprises six cognitive aspects that measure student clinical judgment, from recognizing cues to evaluating outcomes.

The National Council of State Boards of Nursing (2019) identifies recognizing cues as the nurse's ability to identify key findings from assessments, the electronic medical record, and other pertinent sources of subjective and objective data. The nurse can then identify the most concerning or pressing risks to the client's health (analyze cues). Once the key information is recognized and analyzed, the nurse identifies priority hypotheses to address. To generate solutions, the nurse identifies desired client outcomes and possible nursing actions. Taking action occurs when the nurse implements the priority nursing actions. Finally, the nurse evaluates outcomes by comparing the client's actual with the desired outcomes to determine if the client is improving or worsening.

Based on the need to prepare faculty to foster student clinical judgment and the faculty needs assessment results, the aims of the project included:

1)

Design and implement an evidenced-based faculty development session to support faculty use of the NCSBN-CJM to guide their teaching and evaluation.

2)

Increase the use of the model in the nursing curriculum.