On any given day, nurses may need to make dozens of split-second judgment calls. When these situations arise, they must use clinical judgment to fully understand the situation, assess their options, and ultimately make the best choices for their patients.
To create a standardized process for exercising clinical judgment, the National Council of State Boards of Nursing (NCSBN) developed the Clinical Judgment Measurement Model (CJMM), which is widely accepted across the field.
Even after passing the NCLEX exam, nurses must be prepared to utilize the clinical judgment model and demonstrate proficiency in the workplace.
When nurses apply CJMM to their own practice, they can optimize patient safety by minimizing the risk of errors and making timely decisions and accurate assessments. From preventing medication errors to helping nurses choose the correct treatment path, CJMM can improve quality of care while building nurses' confidence.
The six cognitive steps of CJMM are as follows:
During this critical first step, nurses should gather data as it relates to a patient's condition and needs. This may include not just observing a patient's vital signs but also reviewing relevant health records, lab results, and other patient cues.
During this step, situational awareness in nursing is critical. Nurses must be able to perceive relevant cues, understand their importance, and anticipate what might happen next — skills that are difficult to develop without hands-on experience.
Nurses are encouraged to use a method known as rapid red-flag scanning to pinpoint signs of potentially serious or life-threatening conditions. This may include being able to recognize and analyze cues that could indicate symptoms of stroke or sepsis, both of which are time-sensitive. Common sepsis early warning signs include confusion, shortness of breath, and elevated heart rate.
After taking inventory of relevant cues, nurses move to the next phase of CJMM, where they effectively link those cues to a patient's current needs.
At this step, nurses are looking more closely at signs and symptoms to determine how they might relate to the patient's current condition. This process helps them identify possible patterns or underlying issues and begin forming hypotheses that will be tested and refined in the next step.
During the analysis phase, nurses should be especially careful to avoid anchoring bias. Put simply, anchoring bias in healthcare occurs when a nurse relies too heavily on the first piece of information they receive or perceive about a patient. This can lead to missed diagnoses and ineffective treatment.
After closely analyzing cues and considering potential hypotheses, nurses move onto the next phase of the process — which is to determine which issues are the most pressing and prioritize a single hypothesis.
When the best course of action isn't immediately clear, nurses should rely on risk stratification to effectively categorize patients based on their risk level, presenting symptoms, and underlying health factors. This approach allows nurses to prioritize care, allocate resources appropriately, and make informed decisions even when diagnostic information is incomplete.
When time permits, nurses should collaborate with other healthcare professionals to explore additional hypotheses and treatment options. Interdisciplinary collaboration — whether through consultation with physicians, specialists, or other members of the care team — helps validate assumptions, reduce bias, and ensure that care decisions are supported by multiple perspectives.
Once a hypothesis is prioritized, nurses must work quickly to begin generating potential solutions and a viable course of action for the patient's well-being.
The most important part of this step is to match the most relevant, appropriate intervention to the most likely cause of the patient's symptoms. If a nurse suspects that a patient's chest pain is being caused by a heart attack, the most appropriate intervention may be to begin emergency response (such as using a defibrillator).
Resource and constraint awareness involves recognizing the practical limits that can affect clinical decision-making, such as time pressures, staffing levels, equipment availability, and organizational policies. This step can be challenging because nurses don't always have immediate access to the resources or time needed to connect hypotheses and treatments.
Once nurses have confidently linked the patient’s signs and symptoms to a specific hypothesis, they can move forward with implementing the appropriate interventions. This stage involves putting the care plan into motion based on evidence, clinical reasoning, and patient needs.
Effective communication is essential once action is taken. Collaboration and structured handoff tools — such as SBAR communication (situation, background, assessment, and recommendation) — can convey the most important and relevant information about a patient, ensuring that physicians and other healthcare professionals are in the know.
During implementation, nurses must adhere to strict safety protocols to prevent errors and protect patient well-being. For example, when administering certain medications, nurses need to apply high alert medication safety protocols to avoid accidental overdoses or dangerous drug interactions.
The final step of the process involves reviewing the effects of the treatment, which is critical to evaluating long-term outcomes in nursing.
A common strategy used here is rapid reassessment, where nurses quickly focus on life-sustaining functions (like breathing and circulation) to determine whether a patient's condition is improving, staying the same, or worsening. This, in addition to post-intervention reassessment, can inform further interventions.
Nurses are also required to document clinical judgment in their work by writing reports and notes in patient charts. This establishes a record of care (as well as the reasoning behind it). It also protects privacy by facilitating closed-loop communication between nursing staff and other healthcare team members.
With its comprehensive nature, the NCSBN clinical judgment model can be readily applied across a wide range of healthcare settings.
In medical-surgical care and telemetry, nurses can use the clinical judgment model to spot small but significant changes in a patient's condition — such as an altered heart rhythm during surgery that may warrant further investigation.
In critical care and emergency department settings, nurses rely on CJMM to quickly evaluate and take action in potentially life-or-death scenarios. Using early warning score nursing tools and rapid red-flag scanning, ED nurses can apply the right interventions when every second counts.
In long-term care and community home settings, nurses apply CJMM to ensure that patients receive a holistic assessment that takes any existing conditions into account. This approach allows nurses to develop individualized care plans that address both medical needs and quality-of-life factors, supporting patient comfort, independence, and long-term well-being.
Today, nurses have a wide range of tools at their disposal to foster collaboration among themselves and other healthcare professionals.
Clinical practice tools, such as electronic health records and handoff communication tools, allow nurses to collaborate and share relevant patient information more effectively with other providers. This level of coordination ensures that every member of the care team has access to accurate, up-to-date information.
Tools like clinical decision support systems (CDSSs) are seeing increased adoption among healthcare facilities, offering teams real-time recommendations based on factors such as patient history. While not a substitute for CJMM, these systems can be incredibly useful for nurses in choosing the right interventions.
So, how is clinical judgment taught to nursing students? While the process is honed with experience over time, there are some practical ways in which nurses and nursing students can learn CJMM.
Simulations are among the most effective methods for teaching nurses to master the clinical judgment in nursing model. Through simulated experiences, nurses engage in realistic clinical scenarios using high-fidelity manikins or virtual tools that replicate real patient conditions. These controlled environments allow nurses to assess, diagnose, and intervene without the risk of patient harm.
Some healthcare facilities also use unit learning systems, or models where a unit of the facility is used as a teaching/learning environment, to immerse nurses in the realities of clinical judgment. Within these units, novice nurses practice alongside experienced staff, applying CJMM principles in real-time patient care.
Over the course of a nurse's career, clinical judgment is a skill that is continuously refined and improved upon. In this sense, nurses and other healthcare professionals are never truly done sharpening their clinical judgment abilities.
During the clinical judgment process, nurses can improve their own efficiency by learning how to prioritize tasks, cut back on distractions, and seek input or collaboration from other professionals when time allows. Sustaining focus under pressure requires intentional pacing and mental awareness, allowing nurses to process information clearly and make thoughtful decisions.
Clinical care can be improved upon by focusing intentionally on that last step of the process: evaluating outcomes. Even after nurses have finished their shifts, taking time to reflect on what happened — including what went right and what didn’t — can help nurses make more confident, informed decisions in the future.
When time is of the essence, start by scanning for red flags (such as sepsis or stroke). Then, form a quick "worst-case" hypothesis and launch safety actions swiftly, communicating SBAR while gathering and confirming data as needed. While the individual steps of CJMM may be abbreviated or compressed, they all still apply.
If something seems "off" with a patient, even if vitals and other signs are normal, try to focus on the whole picture. This may require a reassessment and expansion of the data you're collecting (such as orthostatics or a glucose-focused exam). If available, explore options for low-cost tests or closer monitoring, remembering that you should always escalate if the risk is asymmetric.
Nurses should be careful never to cling too tightly to their first impression of a patient. Instead, try naming your leading hypothesis and list at least two alternatives to explore. Then, you can use a differential grid and apply "Could this be something else?" prompts during huddles to force reconsideration and other potential explanations.
New nursing graduates are encouraged to practice CJMM prioritization by using worst-first lists that are color-coded to acuity, as well as by simulating 10-minute sprints in their everyday work. Seeking real-time feedback from fellow healthcare professionals and preceptors can also be a great way to pinpoint both strengths and potential areas of improvement.
In addition to vitals, each action should be matched to an expected effect and timeframe when evaluating patient outcomes. For example, when using a bronchodilator, a nurse may expect to see steady breathing within 10 to 15 minutes. From there, symptoms should be re-evaluated, trajectory determined, and results documented for comparison.
In simplest terms, CJMM guides when and why to trigger certain protocols. Specifically, CJMM is used to confirm the fit of a protocol, adapt to context, and stop a protocol or intervention early if the patient's response diverges.
Nurses administering high-alert medications in high-pressure situations should get into the habit of pausing for a double-check, as well as verifying the medication’s indication against patient cues. It’s also a good idea to predefine any applicable reversal or rescue steps before moving forward. If any uncertainty persists, it's always best to be safe and escalate the situation.
Knowing how to apply the NCSBN clinical judgment model is an essential skill for any nurse and can make a huge difference when it comes to patient outcomes. At the same time, proficiency with CJMM can improve professional competency and empower nurses to work and face any situation with confidence, which can enhance career satisfaction.
If you're interested in a career in nursing or are ready to advance your nursing education, Indiana Wesleyan University has programs to suit your needs. Get in touch to learn more about our online and on-campus nursing programs or start your application now.
