10/18/2020
Clinical Judgment for the
Next Generation NCLEX and
Improving Patient Outcomes
Using the Caputi Clinical Judgment
Model/Framework
Presented by:
Linda Caputi, MSN, EdD, RN, CNE, ANEF
4 Educational Reasons to Teach CJ
1. Increase NCLEX pass rates on the current
NCLEX
2. Increase retention; students often don’t progress
because they cannot pass exams that require
application and higher levels of thinking.
3. Increase students’ ability to engage in clinical
judgment for the NGN. The CCJM/F aligns with
the NGN’s CJ measurement model they will use
with the NGN.
4. Improve patient outcomes.
©2020, Linda Caputi, Inc.
Clinical Judgment Abilities of New
Nursing Graduates
Del Bueno (2005) research (old but using it for
comparison):
Only 35% of new RN graduates, regardless of
educational preparation & credentials, meet entry
expectations for clinical judgment.
Kavanagh & Swzeda (2017) Research:
Only 24% of new RN graduates, regardless of
educational preparation & credentials, meet entry
expectations for clinical judgment.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
1
10/18/2020
Muntean’s Study from the NCSBN
Muntean, (2013) from the NCSBN reported, that
although nursing education has been teaching
thinking their research revealed:
50% of novice nurses were involved in errors of
nursing
65% of the errors were due to poor clinical decision
making skills.
80% of employers are NOT satisfied with the decision
making skills of new graduates.
Should we rethink how we are teaching thinking?
©2020, Linda Caputi, Inc.
2019 Review of the Literature Revealed:
Nurses with good clinical judgment skills can have a
positive impact on patient outcomes.
Nurses lacking clinical judgment skills often fail to
recognize clinical deterioration which can result
in compromised patient safety.
***There is limited evidence to support the current
methods of teaching and learning used to foster
clinical judgment to facilitate the development
of basic clinical judgment.
©2020, Linda Caputi, Inc.
Tyo & McMurray, 2019, January/February,
Nursing Education Perspectives
Clinical Judgment, the NGN, and
Thinking in Practice
The NCLEX is changing for the purpose of
achieving higher fidelity with the way a nurse is
expected to think in practice.
Changing the way we teach thinking will provide
positive outcomes for both – NGN and
practice.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
2
10/18/2020
The NCLEX is Changing:
What does that Mean for Nursing
Educators?
It might mean Fear about:
1. Evidence that we need to increase the students’
ability to engage in clinical judgment.
2. The dilemma: haven’t we been doing this? Aren't we
teaching students to use clinical judgment? Why
should I change? How should I change?
3. How to teach CJ in a different way is the unknown
– it’s natural to fear the unknown.
©2020, Linda Caputi, Inc.
How do we teach students now?
1. Teach students content.
2. Present case studies and ask students
questions about the content and what actions
they will take.
3. Prepare questions to ask students when
working through case studies, in the clinical,
and in simulation. Ask as many questions as
possible. Ask those questions over and over
and in many situations.
This isn’t working!
©2020, Linda Caputi, Inc.
What Some May Advocate as New, but is
Actually More of the Same Approach
1. Use the NCSBN’s Clinical Judgment
Measurement Model.
2. There are 6 very general cognitive skills in this
model:
•
•
•
•
•
•
Recognize Cues
Analyze Cues
Prioritize Hypotheses
Generate Hypotheses
Take Action
Evaluate Outcomes
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
3
10/18/2020
What Some May Advocate as New, but is
Actually More of the Same Approach
Questions:
• What thinking does the student have to do to
work through each of those cognitive skills?
• If I write some questions that I think engages the
students in ways I think might be needed for the
NGN, then keep asking these same questions, am
I teaching clinical judgment? Will this approach
work?
©2020, Linda Caputi, Inc.
For Example
1. Give a scenario
2. List some nursing actions.
3. For “analyze cues”: Ask students to choose
those that are indicated, contraindicated, or
non-essential.
The students may or may not know “why” they
answered the way they did, or they may explain
using learned content, but you don’t know how
their THINKING got them to that answer.
©2020, Linda Caputi, Inc.
This is Basically the “Old” Way
The old way is wrapped in new verbiage (using the
NCSBN’s Clinical Judgment Measurement
Model).
But….the instructional strategies are the same.
There’s still the most important piece that is
missing…..
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
4
10/18/2020
The Missing Piece: How did you get to the
answers to the questions?
That’s the missing piece!
The “how did you get there” answer.
The lesson:
Repeatedly asking the same questions in many
different patient situations is not enough to
result in high quality clinical judgment.
Question: Why is that not enough?
©2020, Linda Caputi, Inc.
What Some May Advocate as New, but is
Actually More of the Same Approach
Because…..
The students “get good” at answering YOUR
questions, but did not learn a process to use for
applying clinical judgment when answering.
AND
They did not learn how to formulate THEIR OWN
questions.
What if your questions don’t work in a situation, how
will they know how to proceed?
©2020, Linda Caputi, Inc.
Becoming a Self-regulated Thinker
Students must become self-regulated thinkers!
Self-regulated thinkers MUST know how to engage
in clinical judgment and MUST know what
questions to ask – not have those questions “fed” to
them.
So is asking questions bad?
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
5
10/18/2020
Is Asking Questions Bad?
No…but yes if the student can’t explain their
thinking in terms of thinking and not just content.
This is an opportunity to innovate – to develop a
new way to teach clinical judgment that isn’t a
rewording of what has always been done – which
is no longer working according to the research.
Let’s get started!
©2020, Linda Caputi, Inc.
The #1 issue: Students are not
Learning to Think
The teaching strategy previously discussed
require students to APPLY thinking, but they
have never learned HOW to think.
We must teach the thinking process before they
can apply thinking.
Additionally – you cannot TEST thinking if you
didn’t TEACH thinking.
©2020, Linda Caputi, Inc.
Quick Question
Do you have a program-wide approach or do
faculty determine their own way of teaching
thinking?
Answer “Yes” if you do and “No” if you do not.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
6
10/18/2020
Let’s Look at Some
Questions
You’ve likely already seen these so we’ll look
quickly.
Some example questions from the NGN.
©2020, Linda Caputi, Inc.
Extended Multiple Response (EMR)
CLOZE
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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10/18/2020
Extended Drag & Drop (DD)
Hot Spot (HS)
Dynamic Exhibits & Constructed Response (CR)
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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10/18/2020
Bloom’s Taxonomy
Remembering, understanding, applying, analyzing,
THEN:
the last two levels are evaluating and creating.
With the current NCLEX style and faculty-made items
that are based on one scenario and limited responses,
the highest level that can be tested is the analysis
level.
This is changing with the NGN.
©2020, Linda Caputi, Inc; www.LindaCaputi.com
Cognitive Activities in the Evaluating
Level
• Make judgments based on criteria and standards
• Detect inconsistencies within a process.
• Determine if conclusions follow from observed data.
• Judge which of two methods is the way to solve a
given problem
©2020, Linda Caputi, Inc; www.LindaCaputi.com
Evaluating Level Test Item
• Determine if conclusions follow from observed data:
The question about the nurse’s intervention based on
the documented assessment. Were the nurse’s action
incorrect?
©2020, Linda Caputi, Inc; www.LindaCaputi.com
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
9
10/18/2020
Cognitive Activities in the Creating
Level
• Put elements together to form a new coherent or
functional whole.
• Reorganize elements into a new pattern or structure
©2020, Linda Caputi, Inc; www.LindaCaputi.com
Creating Level Test Item
• Reorganize elements into a new pattern or structure.
• The candidate is presented with the nurse’s
intervention based on the documented assessment
(evaluating level) then the candidate must provide a
free-form answer about what should have been done
(creating). The candidate must reorganize the data into
a new structure (decide on the correct intervention
based on criteria).
©2020, Linda Caputi, Inc; www.LindaCaputi.com
Remember
You can’t test it if you didn’t teach it!
How do you teach students to think so they will
be able to answer these types of questions at
these high cognitive levels?
©2020, Linda Caputi, Inc; www.LindaCaputi.com
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
10
10/18/2020
Two Steps to
Teaching Clinical Judgment
Step 1: Students learn Clinical Judgment: the
process using a model and framework
Step 2: Students apply the clinical judgment
process using the model/framework they learned.
Step 1 is the missing piece and what we need to
change.
• How do we teach that missing piece?
• What can nurse educators do?
©2020, Linda Caputi, Inc.
Now is the Time
We must start immediately to implement a new way of
teaching thinking so students learn to think before
they are asked to apply thinking.
2023 – coming fast!
Don’t wait for a standardized testing company or an
NCLEX review company to do this for you. You
must do it for yourselves. It has to be a priority in
your curriculum that is taught at the beginning
and integrated throughout.
©2020, Linda Caputi, Inc.
The Old Way: In More Detail
1. Teach students content.
2. Define critical thinking – or whatever word you
use.
3. Describe the characteristics of a thinker.
4. Present a general problem solving process such as
the nursing process or the scientific method with
general categories of thinking.
5. Provide examples of how thinking was used in
various situations in your discipline.
6. Challenge students with questions to answer, case
studies to figure out, problems to solve. If they
answer correctly, it is assumed they know how to
think.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
11
10/18/2020
The Old Way Revised
1. Teach students content.
2. Define critical thinking – or whatever word you use.
3. Describe the characteristics of a thinker.
4. Present a general problem solving process such as the
nursing process or the scientific method with general
categories of thinking.
5. Teach a thinking model/framework that provides the
details of thinking in each step – the missing piece.
6. Provide examples of how thinking was used in various
situations in your discipline.
7. Challenge students with questions, case studies,
problems to solve. If they answer correctly, it is
assumed they know how to think.
©2020, Linda Caputi, Inc.
Specific Plans to Teach Clinical Judgment
Must include a planned, consistent approach to
teach clinical judgment across the curriculum that
all faculty use, just as you plan all the other
components of the curriculum – nursing content,
psychomotor skills, simulation scenarios, clinical
experiences, etc.
Not helpful for each faculty to determine their own
way of teaching thinking. That is the old way of
doing which hasn’t worked very well.
©2020, Linda Caputi, Inc.
Specific Plans to Teach Clinical Judgment
The NGN will require students learn a clinical
judgment model. I am offering one for your
consideration.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
12
10/18/2020
Recommended by the NCSBN
In the Spring, 2020, issue of the National Council of
State Boards of Nursing’s publication Leader to
Leader, Dr. Nancy Spector listed some resources to
use to teach clinical judgment.
My editorial titled “Reflections on the Next
Generation NCLEX with Implications for Nursing
Programs” that explained my approach to teaching
clinical judgment was listed as a resource for faculty
to use. The editorial briefly outlined the model I am
presenting to you today.
©2020, Linda Caputi, Inc.
The Caputi Process for Teaching Thinking
in Nursing: A Deliberate Process
Develop a separate course concurrent with the
first clinical course.
Or,
Integrate into an existing course – this is often
tricky!
This is teaching clinical judgment in theory – in the
classroom.
©2020, Linda Caputi, Inc.
Teach the Concept of Clinical
Judgment
Unpack the concept of clinical judgment breaking it
down into its parts:
•
Benner’s Theory
•
Tanner’s Clinical Judgment Model
•
Caputi’s Clinical Judgment Competencies
Thinking must be deconstructed, the pieces taught,
then reconstructed.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
13
10/18/2020
Key Components of the Caputi
Clinical Judgment Model/Framework
Caputi’s
Clinical
Judgment
Competencies
Tanner’s
Model
Clinical
Judgment
Benner’s
Theory
All Pieces Must Come Together
©2020, Linda Caputi, Inc.
Model vs. Framework – Some Definitions
Model:
A representation, generally in miniature, to show
the construction or appearance of something.
Framework:
A structure composed of parts fitted and joined
together.
©2020, Linda Caputi, Inc.
This is the Model
Caputi’s CJ
Competencies
Tanner’s
Model
CJ
This is the
Framework
Noticing
1. CJ Competency
2. CJ Competency, etc.
Benner’s
Theory
Interpreting
1. CJ Competency
2. CJ Competency, etc.
Responding
1. CJ Competency
2. CJ Competency, etc.
Reflecting
1. CJ Competency
2. CJ Competency, etc.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
14
10/18/2020
Operationalizing Clinical Judgment: The
Pieces
All the pieces are based on research rendering the
model for teaching clinical judgment evidencebased.
We’ll look at the pieces, then put them together to
formulate a plan for teaching students
thinking in nursing.
©2020, Linda Caputi, Inc.
Benner’s Novice to Expert
These 5 stages are all about the way a nurse develops
clinical judgment.
©2020, Linda Caputi, Inc.
Stages of Novice to Expert
Novice:
• No experience of the situation
• Must deconstruct (put into simpler, out of context
terms) the content so the student without
experience can understand it
• The student uses rules to follow and applies them
to all situations, regardless of context
Nursing is not black or white, but gray.
What does that mean when you say that to a
student?
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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10/18/2020
Stages of Novice to Expert
Advanced Beginner:
•Begins to apply rules to real situations that result in
learning differences from case to case
•Moves from simple rules to guide behavior to
applying principles to guide actions
•Begins to realize aspects of a situation that are
relevant and those that are not relevant based on
the specifics of a situation; that is, experiences
become situation driven rather than rule driven
•Although the situation is looked at more completely,
there are still many complexities that overwhelm and
exhaust the nurse.
•This is the level of the student at the time of
graduation.
©2020, Linda Caputi, Inc.
Moving Students into the Advanced
Beginner Stage
• Novices use rote memorization of information
applied “as is” to all situations.
• Advanced beginner thinkers apply the rules to the
individual situation. This requires a lot of deliberate
practice with guided cognition using application
activities in the classroom, clinical, simulation, etc.
©2020, Linda Caputi, Inc.
Advanced Beginner
The shift from rule-based to situation-based
thinking.
Must move from rote memorization of rules to
analyzing a situation then determining how to
apply the rule based on each unique
situation and the various aspects of each
situation.
Being able to recognizes nuances among patients.
We’ll work through how that happens.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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10/18/2020
Tanner’s Model of Clinical Judgment
• Noticing: What did you notice?
• Interpreting: What does it mean?
• Responding: What will you do?
• Reflecting: What was the effect of your
thinking? Did your thinking work?
©2020, Linda Caputi, Inc.
Limitation of the Tanner Model
Note: The important message here is that before
students can engage in clinical judgment they
must FIRST learn the specific clinical judgment
competencies needed to carry out each step
of that process.
Tanner’s model just gives the 4 steps of the
process, the FACULTY must fill in the blanks
with the clinical judgment competencies and
how to use them in nursing.
©2020, Linda Caputi, Inc.
The Third Piece:
Clinical Judgment Competencies
What are the clinical judgment competencies??
The detail – studying the actual clinical judgment
competencies (thinking skills and strategies) used in
each step of Tanner’s Clinical Judgment Model.
We must drill down to the details! This is the
missing piece. It’s all about the details.
Incorporating Caputi’s Clinical Judgment
Competencies
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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10/18/2020
Caputi’s CJ Competencies Associated
with the Steps of Tanner’s Model
1. What did you notice? (Noticing)
• Identifying signs and symptoms
• Gathering complete and accurate data
• Predicting potential complications
• There are more
©2020, Linda Caputi, Inc.
Caputi’s CJ Competencies Associated
with the Steps of Tanner’s Model
2. What does it mean? (Interpreting)
• Clustering related information
• Recognizing inconsistencies
• Distinguishing relevant from irrelevant
information
• Judging how much ambiguity is acceptable
• Comparing and contrasting
• Managing potential complications
There are more.
©2020, Linda Caputi, Inc.
Caputi’s CJ Competencies Associated
with the Steps of Tanner’s Model
3. What will you do? (Responding)
• Setting priorities
• Delegating
• There are more.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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10/18/2020
Caputi’s CJ Competencies Associated
with the Steps of Tanner’s Model
4. What was the effect of what you did?
• Evaluating data
• Evaluating and correcting thinking
©2020, Linda Caputi, Inc.
The NCSBN’s CJMM Compared to the
Caputi CJM/F
Let’s look at how the Caputi Clinical Judgment
Model/Framework aligns with the NCSBN’s
clinical judgment measurement model.
©2020, Linda Caputi, Inc.
Alignment with the NCSBN CJMM
The NCLEX CJMM
Cognitive Skills
Step in Tanner’s Clinical
Judgment Model
Example Caputi’s CJ
Competencies**
Recognize Cues
Noticing
1.
2.
3.
Identifying signs & symptoms
Gathering accurate information
Predicting potential complications
Analyze Cues
Interpreting
1.
2.
3.
Recognizing inconsistencies
Judging how much ambiguity is acceptable
Identifying assumptions
Prioritize
Hypotheses
Setting priorities
Interpreting
1.
Generate Solutions
Use the Nursing Process to
identify and plan nursing
interventions
Implement the nursing process using the
information from the above CJ competencies.
Take Actions
Responding
1.
2.
Delegating
Communicating
Reflecting
1.
2.
Evaluating data
Evaluating and correcting thinking
Evaluate Outcomes
**These are only examples and not a complete list of the CJ Competencies.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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10/18/2020
How Does the Caputi CJM/F Support the
NCSBN’s CJMM?
Just using the six steps of the NCSBN’s CJMM
(listed on the previous slide) and asking questions
that relate to each step is NOT enough!
That approach is similar to what we have always been
doing.
Nursing education must drill down to the specific
CJ Competencies (thinking skills and strategies)
that are used in each of those six steps of the
NCSBN’s CJMM.
©2020, Linda Caputi, Inc.
Review: How do we teach students now?
1. Teach students content.
2. Present case studies and ask students
questions about the content and what actions
they will take.
3. Prepare questions to ask students when
working through case studies, in the clinical,
and in simulation. Ask as many questions as
possible. Ask those questions over and over
and in many situations.
©2020, Linda Caputi, Inc.
New Way
1. Teach students a detailed model/framework for
thinking – with detailed clinical judgment
competencies – what they are and how to use them.
2. Apply the approach in a very deliberate manner.
3. Once students have learned all the details of clinical
judgment, THEN all faculty role model using this
model/framework when thinking through patient
situations with case studies, in clinical, etc.
4. Students explain their answers in terms of content
AND in terms of the thinking they used to arrive at
their answers.
5. Students generate their OWN questions.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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10/18/2020
This is the Model
Caputi’s CJ
Competencies
Tanner’s
Model
CJ
This is the
Framework
Noticing
1. CJ Competency
2. CJ Competency, etc.
Benner’s
Theory
Interpreting
1. CJ Competency
2. CJ Competency, etc.
Responding
1. CJ Competency
2. CJ Competency, etc.
Reflecting
1. CJ Competency
2. CJ Competency, etc.
©2020, Linda Caputi, Inc.
Teaching the 19 CJ Competencies
Step 1: Teach these competencies – what they are,
how students already know how to use them,
empowering them with this awareness, then
discussing how they are used in nursing.
Step 2: Apply each one in the clinical setting.
Step 3: Continue to apply the model/framework
throughout the rest of nursing courses for the
end goal of students becoming self-regulated
thinkers.
©2020, Linda Caputi, Inc.
Six Specific Steps for Teaching Each CJ
Competency
Step 1: Start with a definition of the CJ competency.
Predicting Potential Complications:
What might go wrong for your patient considering the
assessment data you are collecting?
Caution: Just giving the student the definition does not
go far enough. Always implement steps 2 through 6
to empower students to know how to use the CJ
competency. Without experiencing steps 2 through 6
students won’t know what to do.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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10/18/2020
Six Specific Steps for Teaching Each CJ Competency
Step 2: Give an example using the CJ competency in
everyday life.
When collecting data in the morning about the weather
for the day you hear that half way through your
work day there is a 100% prediction of heavy snow.
What complications might occur for you four hours
after the snow starts, it is time to drive home, and
you have a 45 minute automobile commute home?
You must predict potential complications so you can be
prepared to intervene should the complications
occur.
©2020, Linda Caputi, Inc.
Six Specific Steps for Teaching Each CJ Competency
Step 3: Students relate the CJ competency to their own
life experiences.
The homework for the students that day is to read
about this clinical judgment competency and to
bring to class an example of how they use that CJ
competency in their every day life.
This establishes that they already know and use the CJ
competency.
This empowers them to apply what they already know to
new and different (nursing) situations.
©2020, Linda Caputi, Inc.
Six Specific Steps for Teaching Each CJ Competency
Step 4: Provide a nursing example using the CJ competency
so students can see how that CJ competency is applied
in nursing. (Customize for your discipline.)
Provide a simple nursing example such as:
You are assessing your patient who has weakness on the
left side. Your assessment reveals the patient has
difficulty holding anything in the left hand and states
cannot bear weight on the left leg.
A possible complication will be a fall if improper technique
is used to transfer the patient.
The nurse must predict this potential complication then
plan to prevent it from happening – or know how to
intervene should it occur.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
22
10/18/2020
Six Specific Steps for Teaching Each CJ Competency
Step 5: Provide an additional classroom activity applying
the CJ competency.
Students must have practice using the CJ competency in
the classroom before they are expected to use the CJ
competency in the clinical.
Provide students with the printed version of Millie Larsen,
one of NLN’s ACES patients. Students read through
her narration as she tells her story. They work in small
groups to “predict potential complications” for Millie.
Typically they find that Millie is at risk for complications
such as falls, loneliness, not taking meds due to
financial reasons, nutritional problems for various
reasons, etc.
©2020, Linda Caputi, Inc.
Six Specific Steps for Teaching Each CJ Competency
Step 6: Deliberate practice using the CJ competency in
clinical. Using cognitive guidance tools.
Each student that week in clinical completes a “Cognitive
Guidance Tool” related to this thinking skill.
See tool in the handout.
©2020, Linda Caputi, Inc.
Using Cognitive Guidance Tools
• Use the same thinking tools on a number of patients for
additional practice with thinking throughout the term.
• Comparing and contrasting information for several
patients to discuss how the thinking varied among
different patient situations. Identifying patient
differences – nuances among patients.
• Provides a way to identify and provide feedback on the
student’s specific thinking problems. Learning
interventions can then be developed.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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10/18/2020
Assessing Thinking & Providing Feedback
Faculty can easily assess if students are aware of the
thinking required to solve a patient problem.
Faculty can determine the quality of the student’s
thinking.
Faculty can provide specific, usable, nonjudgmental
feedback.
Not: You need to work on your critical thinking.
Rather: You did a good job “Assessing Systematically and
Comprehensively”; let’s work on “Predicting Potential
Complications.”
This is analogous to providing feedback on a skill “return”
– you are very specific. Let’s use that same approach
with thinking!
©2020, Linda Caputi, Inc.
Let’s Consider Another Cognitive
Guidance Tool
• Let’s look at another activity.
• Refer to the “Vital Signs Activity” in the handout.
©2020, Linda Caputi, Inc.
Using this Type of Guidance
Use this type of guidance and these tools in all learning
environments:
• Classroom when working through case studies
• Clinical
• Skills laboratory
• Simulation
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
24
10/18/2020
Self-Directed Thinking
As students work through the program, you wean
them off the cognitive guidance tools (clinical
activities) and have them explain their thinking
using the model/framework to guide their thinking.
©2020, Linda Caputi, Inc.
Example: Noticing Step & Thinking Skills
The student assessed the patient and determined the
patient was experiencing a problem with perfusion.
The student will explain their thinking using the CJ
Competencies:
1. Identify Signs and Symptoms:
Bluish facial skin color; difficulty arousing.
©2020, Linda Caputi, Inc.
Example: Noticing Step & Thinking Skills
2. Assess Systematically & Comprehensively
Using my knowledge of perfusion, I considered all
assessment data to collect that is influenced by
decreased perfusion such as:
• Nail beds; capillary refill
• Pulse oximetry, BP, Pulse
• Lung sounds; respiratory rate and character
• Oxygen in use and flowing? Positioned for lung
expansion?
• LOC; oriented X4; dizziness
• Previous interventions, medications
• Review patient record to determine past documentation
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10/18/2020
Example: Noticing Step & Thinking Skills
3. Gather Accurate Information
How I knew the data I collected are accurate?
Accurate data collection first starts with my level of
knowledge of perfusion, related pathophysiology, and the
individual patient situation. I must be fully informed.
Determining accuracy of data collected:
• Pulse Ox: if unsure the equipment is working correctly,
take my own pulse ox to test the device
• Lung sounds: if in doubt ask another nurse to assess
• Ensure oxygen is flowing
• Determine patient’s ability to provide reliable information
©2020, Linda Caputi, Inc.
Example: Noticing Step & Thinking Skills
4. Predict Potential Complications
While assessing the patient I collected assessment data
about potential complications that may occur:
• Injury such as a fall from dizziness or decreased
cognition.
• Respiratory distress to respiratory arrest.
• Other areas to assess for potential complications:
• Safety
• Anxiety
• Mobility
©2020, Linda Caputi, Inc.
Teaching the CJ Competencies
These last 4 slides walk the student through the experience
about how the nurse actually thinks in the Noticing Step –
but the nurse does this thinking in such quick fashion it is
difficult for the nurse to even articulate the process.
This is why WE must slow walk the students through the
thinking, providing the framework and cognitive guidance
tools to provide them practice, practice, practice.
Once implemented for a semester or two the student works
through the thinking much faster as well as engaging in the
thinking automatically. That is the goal!
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
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Goal of this Revised Approach
Graduates who are self-regulated thinkers, not
just graduates who have had lots of practice
solving problems and answering your questions
based on content, but can also……
©2020, Linda Caputi, Inc.
Goal of this Revised Approach
1. Guide their own thinking; become self-regulated
thinkers.
2. Know what thinking skills & strategies to use
when applying the nursing process, scientific
method, other process you use.
3. Formulate their own questions rather than only
answering teacher formulated questions.
4. Explain in very specific terms how they learned
to think and how they solve problems using
specific terms rather than general terms such as:
“I use the nursing process.”
©2020, Linda Caputi, Inc.
Goal of this Revised Approach
Students need to be able to explain their thinking
processes and how they used them to arrive at an
answer – NOT explaining their thinking just in terms
of content.
Without a specific approach (model/framework)
they are ill-prepared for new situations they
encounter.
©2020, Linda Caputi, Inc.
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10/18/2020
Do you already do this?
• It may appear on the surface that you already do this.
Especially if you ask students to explain their thinking,
their rationale for how they arrived at their answers.
• This is the “content” part of the steps previously
outlined.
• It is NOT the “explain your thinking” in terms of the
actual thinking skills & strategies (clinical judgment
competencies) they used.
• Without this explanation of their thinking and their
awareness of the thinking skills they are using, they are
not able to transfer the “lessons learned” related to the
thinking process from one situation to another.
©2020, Linda Caputi, Inc.
Becoming a Self-regulated Thinker
Students must become self-regulated thinkers!
Self-regulated thinkers MUST know how to
engage in clinical judgment (thinking) and MUST
know what questions to ask – not have those
questions provided for them.
©2020, Linda Caputi, Inc.
The Key to Success
Make teaching clinical judgment something that is
doable and understandable for the student.
Most texts present an in-depth study of the
theoretical basis but do not get to the “how to”
piece in an organized, objective, and
understandable way for students.
We teach the nursing process BUT we must teach
the thinking behind the nursing process – that is
what I am talking about here!
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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10/18/2020
The Detailed Steps for Teaching Each CJ
Competency: This is the Missing Piece
Most students cannot explain in any certain way how
they learned to “think like a nurse”.
We tell them they must “think like a nurse” and we
explain how we would approach a situation to
role model “thinking like a nurse” – but we don’t
teach what the actual thinking process is!
Each student may have their own perception of how
they learned to think, but likely can’t explain it.
©2020, Linda Caputi, Inc.
Summary
• You would use these same 6 steps for teaching each of the
CJ competencies in the first term with application in
clinical during the first clinical course.
• These tools are then adapted to various patient
populations in the following semesters – acute care,
pediatrics, obstetrics, mental health, long-term care, home
health, etc. Nurses in all environments think in the same
way, so the tools can be adapted to meet your needs in
these various environments.
• Then in subsequent courses, demonstrate use of these CJ
competencies in class, simulation debriefing, and clinical,
with specific higher-level thinking activities applied to
more complex cases and situations.
©2020, Linda Caputi, Inc.
Summary
• All faculty use the same model/framework.
• All faculty use the verbiage of the clinical judgment
competencies as they work with students in the
classroom, clinical, simulation, and skills laboratory.
• Students hear the same language and use the same
approach throughout the nursing program for the goal
of:
Becoming a self-regulated thinker by the end of the
program!
• Students must be able to direct their own thinking – but
they need a process for doing this!
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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10/18/2020
Using the Framework Across Learning
Environments
• The framework is used in simulation debriefing and in
clinical to discuss how decisions were made.
• The framework is used in the classroom when
discussing case studies.
• Faculty use the framework when explaining how they
solved a specific patient problem – using the CJ
Competencies to explain their thinking. THIS is a
major CHANGE from the way we are used to
explaining to students how we would approach a
problem. It does require faculty to think about their
own thinking.
©2020, Linda Caputi, Inc.
A Major Point to Make
• We always say to students they need to learn to
“Think Like a Nurse”. But we don’t specifically and in
detail explain what that looks like!
• We must explain in specific terms what “Think Like a
Nurse” means.
• That is the void the CCJM/F fills. We don’t just say
“Think Like a Nurse”, we teach students what that
means – in a clear, understandable way -- and give
them lots of practice using the process as they apply
thinking to nursing practice.
©2020, Linda Caputi, Inc.
How to Teach Thinking Across the
Curriculum
Semester 1: Teach all the CJ competencies using the
6 steps.
Semester 2: Continue to use the same tools so
students can master that type of thinking.
Semester 3: Use some of the same tools applied to
more complex patients; start using more
advanced level tools/activities.
Last semester: Not using tools, but using the
thinking framework to explain all their thinking.
©2020, Linda Caputi, Inc.
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10/18/2020
Students Can Articulate How They
Think
Think about graduates interviewing for a nursing
position and they are asked, “Tell me how you
think through a patient problem.”
Will your graduates’ answer be something like this:
©2020, Linda Caputi, Inc.
Students Can Articulate How They Think
Well, I use a clinical judgment model/framework. I first
notice what is going on by identifying signs &
symptoms, assessing systematically and
comprehensively, gathering accurate information,
and predicting potential complications.
Then I need to interpret the data by recognizing
inconsistencies, determining the importance of
information – then from the important information I
distinguish relevant from irrelevant information for
a problem I identify the patient is experiencing.
Then……………………..
And I do all this thinking to improve patient outcomes.
©2020, Linda Caputi, Inc.
The Bottom Line
The important message is this:
1.
Before students can engage in clinical
judgment they must FIRST learn the specific
clinical judgment competencies needed to
carry out each step of the Clinical Judgment
model. They must learn how to think!
2.
You cannot test clinical judgment if you
didn’t teach clinical judgment.
©2020, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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10/18/2020
Change is Hard; Change is Needed
This approach -- especially when implemented
consistently across all clinical groups across all terms
of the program -- provides an intense method for
studying clinical judgment with in-depth application to
patient care.
This is a change to the way we have been teaching
clinical judgment for decades.
A change is needed to do well on the NGN. The old
way won’t work.
©2019, Linda Caputi, Inc.
Summary
• What has been presented today is a general
overview.
• To truly reframe your curriculum, you must “drill
down to the detail” to reframe what you are
currently doing to teach thinking in a new way.
• This requires deliberation, team work, action, and
the desire to reframe.
©2019, Linda Caputi, Inc.
Stop and Talk
Consider what has been presented.
How will you implement this in your program?
How will you implement this in your course?
©2019, Linda Caputi, Inc.
©2020 Linda Caputi, Inc. www.LindaCaputi.com
LindaJCaputi@gmail.com
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Thank you for sharing your time
with me!!!
©2019, Linda Caputi, Inc.
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