Preparing for the Next-Generation NCLEX® (NGN): Shifting from the Nursing Process to Clinical Judgment in Nursing

Preparing for the Next-Generation NCLEX® (NGN): Shifting from the Nursing Process to Clinical Judgment in Nursing

Understanding the Nursing Process:

The nursing process has been a structured way of solving problems and making safe decisions in patient care for more than 50 years. Initially, there were four main steps in the process, introduced in the late 1960s:

1. Assessment
2. Planning
3. Implementation
4. Evaluation

Later, in the early 1970s, the North American Nursing Diagnosis Association (now NANDA-I) was established to create a common language for standardized nursing diagnoses based on assessment data. This led to an extended version of the process known as ADPIE:

1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

This problem-solving method requires critical thinking and decision-making. It has evolved into clinical reasoning, which is crucial for nursing practice. The 2020 NCLEX-RN® Test Plan recognizes the nursing process as a scientific, clinical reasoning approach to care that involves assessment, analysis, planning, implementation, and evaluation (NCSBN, 2019). Notably, the definition doesn’t include Diagnosis; instead, the second step is referred to as Analysis.

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However, the NCLEX-RN® and NCLEX-PN® do not test nursing graduates on nursing diagnoses (NDs) since they’re not universally used as initially intended. Despite this, many educators continue to teach the five-step ADPIE nursing process.

Comparing the Nursing Process and Clinical Judgment:

Despite teaching the nursing process for years, nurses still make critical errors, leading to patient harm in some cases. To address this, the National Council of State Boards of Nursing (NCSBN) developed the NCSBN Clinical Judgment Measurement Model (NCJMM), building on the nursing process. This model focuses on six cognitive skills essential for effective clinical judgments:

1. Recognize Cues
2. Analyze Cues
3. Prioritize Hypotheses
4. Generate Solutions
5. Take Action
6. Evaluate Outcomes

The NCJMM forms the basis for the Next-Generation NCLEX-RN and NCLEX-PN (NGN) test items, primarily in unfolding case formats. These cases require candidates to apply clinical judgment skills to manage patient care effectively.

Transitioning from the Nursing Process to Clinical Judgment:

For educators mandated to teach the nursing process, there are steps to help shift the emphasis to clinical judgment:

1. Integrate clinical judgment into your program’s definition of professional nursing and student learning outcomes.
2. Present the nursing process as a foundation for clinical decision-making in the initial nursing course.
3. Lessen focus on the NANDA nursing diagnosis list, emphasizing understanding of signs, symptoms, and behaviors that healthcare teams use.
4. Introduce the NCSBN definition of clinical judgment and its cognitive skills early in the nursing program.
5. Encourage students to practice the six cognitive skills through various activities, including unfolding case studies.

Building on the Nursing Process for Clinical Judgment:

Transitioning to clinical judgment aligns nursing practice more closely with how nurses think in real-life situations. Remember that clinical judgment isn’t new, and experts like Tanner have emphasized its importance for years. The NCJMM cognitive skills can be matched with nursing process steps, facilitating the transition:

Comparison of Nursing Process, Tanner’s Clinical Judgment Model, and NCJMM:
– Assessment: Recognize Cues
– Diagnosis/Analysis: Analyze Cues
– Diagnosis/Analysis: Prioritize Hypotheses
– Planning: Generate Solutions
– Implementation: Take Action
– Evaluation: Evaluate Outcomes

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These models may seem alike, but they involve different thinking processes. Transitioning from the nursing process to clinical judgment aligns nursing education better with real-world nursing practice. Remember that clinical judgment will be the focus of the new test items for NGN by 2023. Begin your transition soon, and explore resources on the NCSBN website and Elsevier Evolve Faculty Resources webpage.

Reference:

National Council of State Boards of Nursing (NCSBN). (2018). NCLEX-RN® Examination: Test plan for the National Council Licensure Examination for Registered Nurses. Chicago, IL: Author.